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THE 

INFLUENCE OF GROWTH 



ON 



CONGENITAL AND ACQUIRED 
DEFORMITIES 



By 

ADONIRAM BROWN JUDSON, A.M., M.D. 

Orthopaedic Surgeon to the Out-Patient Department, New York Hospital, 

I 878-1903 Statistical Secretary of the New York Academy of Medicine ; 

formerly Chairman of the Orthopaedic Section, New York Academy 

of Medicine ; formerly President of the American Orthopaedic 

Association ; Member of the American Medical Association ; 

Fellow of the American Academy of Medicine ; 

Formerly Surgeon U. S. Navy. 



PR O FUSEL I ' II. L USTRA TED 



NEW YORK 

WILLIAM WOOD AND COMPANY 

MDCCCCV 



A 



M 



LIBRARY of CONGRESS 
Two Copies Received 

JAN 24 1905 

y, Copyritftit tntry 
WSS «- XXc. Na 



COPY B. 



Copyright, 1905, by 
WILLIAM WOOD AND COMPANY 



Gbte Book is Beotcatco 

TO MY BROTHER, 

The Rev. Dr. EDWARD JUDSON, 

IN AFFECTION. VI E 
APPRECIATION OF HIS GOOD WORDS AND 

BENEFICENT DEEDS. 



PREFACE. 

The original intention of writing a paper which 
should call attention to the influence of growth has 
led to the preparation of this book. Certain features 
have been included which, although not entirely 
novel in themselves, are yet presented in a new light 
which gives them importance as matters that will 
repay close attention in practice. Among the sub- 
jects thus treated are: the application of the weight 
of the body for the reduction of club-foot, the use 
of the equine position of the foot to increase the 
length of a shortened limb, the adoption of symmet- 
rical movements and correct rhythm for removing 
deformity and excluding lameness, and the manner 
in which misleading tumors are produced by the ro- 
tation of lateral curvature. It is difficult to overlook 
entirely the element of growth when patients are 
with few exceptions children, and in view of the fact 
that the word orthopaedic is derived from two Greek 
words carrying the ideas of straightness and juvenile 
development. A. B. Judson. 

New York, January, 1905. 



TABLE OF CONTENTS. 



PAGE 

Introduction 1-4 

CHAPTER I. 

Congenital Club-foot. 

Treatment at an early stage. — Mechanical details. — Early use of 
adhesive plaster. — Treatment at a later stage. — " Stamping a 
foot straight." — Club-foot of spastic contraction. — Neglected, 
relapsed, and inveterate cases. — Subcutaneous tenotomy. — 
Measurement of degrees of deformity. — Mechanical disad- 
vantages of the human foot. — Hat-foot. — Minor ailments of 
the feet, . . . . 5-32 



CHAPTER II. 

Deformities Caused by Infantile Paralysis. 

Exemption of the upper extremities. — Paralysis of thigh muscles. — 
Of leg muscles. — Talipes calcaneus. — " The Human Wheel." 
— The strain on the tendo Achillis. — Congenital calcaneus. — 
Paralytic varus. — Valgus. — Mechanics of locomotion.— De- 
formities of locomotor ataxia and Friedreich's disease.— Im- 
portance of treatment during growth. — Details of treatment. — 
Recognition of mechanical surgery. — An orthopaedic labora- 
tory. — Apparatus not only prosthetic, but also preventive and 
therapeutic — Orthopaedic surgery as a specialty, . . 33-63 



vin CONTENTS. 

CHAPTER III. 
Tuberculous Joint Disease. 

PAGE 

An affection of childhood. — Predisposing causes. — Operative and 
mechanical treatment. — Intelligent expectation. — Deformity. 
— Fear of ankylosis. — Favorable outcome depending largely 
on early diagnosis, 64-72 

CHAPTER IV. 

White Swelling of the Knee. 

Removal of bodily weight imperative. — By recumbency.— By ax- 
illary crutches. — By ischiatic support. — Arrest of motion by 
leverage of pressure and counter-pressure. — Deformity re- 
duced by the same instrument. — Ultimate mobility compro- 
mised by unreasonable fear of ankylosis.— Treatment 
throughout the growing period. — Subluxation. — Abscesses.— 
Knock-knee.— Bow-legs. — Ankle disease, .... 73-86 

CHAPTER V. 

Treatment of Hip Disease. 

Basis of mechanical treatment. — Historical notes. — Use of adhe- 
sive plaster for traction. — Practical inferences from morbid 
anatomy. — Correlation of traction and fixation. — The Ameri- 
can splint. — Details of application in the third stage. — Weight 
and pulley. — Paradox in treatment of hip disease and frac- 
ture. — Ultimate mobility promoted by fixation. — Management 
of apparatus at home. — Joint disease in the upper and lower 
limbs. — Weight of the body as a factor. — Comparative im- 
portance of traction and protection. — Tuberculous disease of 
wrist, elbow, and shoulder. — The ischiatic crutch. — Its use 
as an artificial limb. — In ununited fracture. — Discontinuing 
treatment. — Overexertion to be avoided after recovery, . 87-129 



CONTENTS. ix 

CHAPTER VI. 
Abscesses of Hip Disease. 

PAGE 

Absorbed, cold, and inflamed abscesses. — Without effect on dura- 
tion and results of disease. — Their origin, significance, and 
deportment. — Location of sinuses. — Question of operation 
or expectation, 130-14 1 

CHAPTER VII. 

Diagnosis, Prognosis, and Appre< iation of Results 
of II ii' Disease. 

Symptoms and signs. — Reflex action the most valuable early sign. 
— Three diagnostic signs of established disease. — To test for 
antero-posterior and lateral mobility. — Structural shorten- 
ing.— Found also in acute epiphysitis, diastasis, infantile 
paralysis, congenital dislocation, and coxa vara.— The syno- 
vitis of continued fever.— Good results depending largely on 
diagnosis before pain appears.— Good functional results after 
the third stage.— Amount of motion less important than posi- 
tion of limb. — Manikin demonstrations. — The goniometer. — 
Ready methods of estimating shortening, . . . 142-169 



CHAPTER VIII. 

Causes and Prevention of the Deformitv of Hip 
Disease. 

Real " less important than " apparent " shortening. — Faulty po- 
sition of the limb. — Fixation the result at first of muscular 
contraction, afterward of ankylosis. — The neuro-muscular 
element. — The movable-immovable joint. — Faulty position 
unconsciously assumed for convenience. — Method of induc- 
ing its surrender. — Illustrations of favorable and unfavorable 
results.— Difficulty of direct mechanical reduction. — Over- 



CONTENTS. 

PA( 

coming structural shortening. — Local hyperemia and anae- 
mia. — Extension shoe. — Equine foot. — Definition of lameness 
in general. — Normal and abnormal rhythm. — Influence of 
growth on correction of deformity, ijo-il 



CHAPTER IX. 

Pott's Disease of the Spine. 

A disease of childhood, but occurring also in the aged.— Signs 
and symptoms. — Local pain and disability often absent. — 
Varying effects of cervical, lumbar, and dorsal disease. — 
Compensating lordosis. — To make a diagnosis before appear- 
ance of deformity. — Recovery through reaction and consoli- 
dation.— Recumbency.— Mechanical support. — Arrest of mo- 
tion. — Transference of weight. — Incidental improvement of 
figure during growth.— A practical rule and mechanical de- 
tails. — Plaster-of-Paris jacket. — Abscesses. — Paraplegia. — 
Reduction of stature. — Caries of sternum, . . . 189-216 



CHAPTER X. 

Lateral Curvature of the Spine. 

Rotation. — Its cause. — Its effect on torso overlooked in art. — 
Diagnosis obvious, but incidental effects of rotation not 
always recognized. — Tumors. — Sciatica. — Sacro-iliac disease. 
— General health and ability not compromised. — Rotating 
curvature a physiological manoeuvre.— Incidental and typical 
curvatures. — Importance of treatment.— Braces. — Treatment 
based on clinical observations. —Recumbency, suspension, 
rest, chest expansion. — Sequence of causes, . . .217-244 



THE INFLUENCE OF GROWTH 



UPON 



Congenital and Acquired Deformities, 



INTRODUCTION. 

I venture to present to the reader a new volume 
on orthopaedic subjects, not because there is any lack 
of excellent systems and text-books, but rather to 
emphasize what seems to lie at the base of practice in 
this specialty, the fact that prevention and cure arc 
to be lOiind in so managing a case and equipping a 
patient that natural growth will be the principal 
factor in recovery. Mr. Hilton said : " Repair is but 
the repetition of growth. The same elements, the 
same kindred conditions are necessary to the same 
results." This view is far from including all there 
is in orthopaedic practice, but the thought thus ex- 
pressed should. temper the consideration of all pro- 
cedures, whether operative or mechanical, which 
have for their object the removal of deformity. 

The average length of a new-born baby is nineteen 
and a half or twenty inches. During the first six 



2 GROWTH AND DEFORMITY. 

months he grows from four to five inches, and in the 
second six months from three to four inches. Dur- 
ing the second year he grows from three to five 
inches; during the third year from two to three 
inches and a half; and during the fourth year from 
two to three inches. By the end of the fifth year the 
child has generally doubled his original length. After 
that his average annual growth is from one inch and 
two-thirds to two inches, with a slight acceleration in 
the years just preceding puberty. This period of 
gradual increase in size, covering nearly a quarter of 
the three score years and ten, may not be neglected 
in intelligent efforts to banish deformity and promote 
physical ability, refreshing the significance of Andry's 
designation of orthopaedic surgery as the "art of 
making a child grow straight." If the surmise is 
correct that the rate of growth is not uniform from 
year to year, but is now rapid and again slow, it 
would be well if fluctuations in the rate could be rec- 
ognized or foreseen, making possible especial ortho- 
paedic efforts when growth is rapid and comparative 
relaxation of treatment when it is progressing more 
slowly. 

The methods of diagnosis, prevention, and treat- 
ment herein presented are put on record as having 
proved useful and as likely to be at least suggestive 
in the practice of others. These pages probably 
contain very little that is new or presented for the 



INTRODUCTION. 3 

first time. So-called new observations and inventions 
in medicine and surgery have generally been made 
before and recorded on some page which for some 
reason or other has not been read. In regard to 
" new truths," it has been wittily said that " what is 
true is not new and what is new is not true." In all 
departments of industry improvements are planned 
some time before they are realized or tested, becau>e 
unfavorable conditions have to be first changed by 
improvements in other departments. Imagination 
walks ever in front of the advancing line of the arts 
and sciences, and no member of the band may pro- 
gress except in company with the rest. In orthopae- 
dic surgery methods have improved, not because 
something new has been learned about disease and 
principles of treatment, but rather because general 
knowledge has increased and difficult mechanical 
effects have become convenient through improve- 
ments in and novel applications of such materials as 
adhesive plaster, gypsum, and steel. The fine ad- 
justments which Fayette Taylor made by ingeniously 
constructed joints in his " spinal assistant " are now 
more readily made in Bessemer steel. Conditions of 
advance are not only physical, but are also found in 
mental attitudes which are liable to change in re- 
sponse to reason and experience. When the fear of 
wounding a tendon was overcome, subcutaneous 
tenotomy was accepted. The fear of ankylosis may 



4 GROWTH AND DEFORMITY. 

in course of time subside, and the views of the surgi- 
cal world may in due order turn in favor of intelli- 
gent expectation in the management of joint diseases, 
thus making good Mr. Hilton's additional words: 
" Rest is the necessary antecedent to the accomplish- 
ment of repair and growth. This is surely the natu- 
ral suggestion of a means toward an end which 
should never be lost sight of by the physician or 
surgeon." 



CHAPTER I. 

CONGENITAL CLUB FOOT. 

The effect of natural growth on deformity is very 
evident in a case of congenital club-foot. A baby 
gains in length from seven to nine inches in the first 
year, in which period the deformity becomes more 
obvious and obstinate with each added month; but 
if the foot is held in a good position, growth intro- 
duces symmetry and facilitates restoration. 

TREATMENT AT AN EARLY STAGE. 

This deformity cannot receive attention too early. 
Dr. Willard says: "The time for beginning the 
treatment of congenital club-foot is at the hour of 
birth." The limb should at once begin to grow 
straight instead of growing crooked. Ready to yield, 
the little foot seems to be held out in an appeal for 
the application of a lever, making points of pressure 
and counter-pressure in the directions indicated by 
the arrows in Figs, i, 2, 3, and 4. A plaster-of-Paris 
dressing observes the same points of action. The 
brace shown in Figs. 3 and 4 may be made of brass 
or other convenient metal. The thin discs are softly 



GROWTH AND DEFORMITY. 



padded. The brace is applied with three strips of 
adhesive plaster and very gradually bent to differ- 
ent shapes, as seen in Figs. 5, 6, 7, and 8, the foot 
taking on corresponding shapes until it occupies the 
concavity of the brace where valgus is seen instead 










Fig. 1. 



Fig. 2. 



Fig. 3. 



Fig. 4. 



<J 






Fig. 5. 



Fig. 6. 



Fig. 7. 



Fig. 8. 



Figs. i-8. — Points of Pressure and Counter-pressure in the Early Stage of 
Treatment, and Changes made in the Brace and in the Shape of the 
Foot. 

of varus. These successive changes took place and 
were carried farther in Case I., as is shown in Fig. 
22, on page 22. Correction cannot well be overdone 
in this stage. The details of this application are pre- 
sented more clearly in Fig. 9, which shows the right 
foot of a boy six months old in process of correction. 



COX(' r EX I TA L CL L r B-FOO T. 



The plaster 'surrounding the leg and the upper shield 

and that surrounding the foot and the lower shield 
are lightly applied as they simply hold the apparatus 
in place. The middle plaster, after being securely 
fastened by several turns 
around the upright, re- 
ceives the unattached 
middle shield and sur- 
rounds the lower part of 
the leg and the brace. 
While one hand reduces 
deformity by forcing the 
limb and brace together, 
let the other hand secure 
the middle plaster after 
repeatedly carrying it 
around the limb and the 
upright of the brace, 
being ever mindful of 
the pressure made by 
the middle shield, which 
is the key to the application. It is needless to say 
that careful attention is required to secure comfort 
and efficiency, which follow the skill born of repeti- 
tion. Under advice and instruction the successful 
carrying out of the necessary details depends on the 
intelligence found in the patient's home. Reduction 
is assisted by the position of the babe " in arms," 




Fig. 9. — Details of Application. 



8 GROWTH AND DEFORMITY. 

where no part of his weight interferes with the me- 
chanical force used. One or two days in each week 
may be given to freedom of the foot and manipula- 
tion in order to maintain flexibility. Without haste, 
violence, or pain, the foot, having doubled its size 
by growth, will be found valgus when resting undis- 
turbed, and the tendo Achillis, as an incidental effect 
and without especial attention, will be sufficiently 
lengthened to permit a right-angled position of the 
foot. This, the first stage of treatment, should be 
concluded long before walking begins. 

Early Use of Adhesive Plaster.— In the case of a 
new-born babe, before a brace can be prepared, the 
trouble may be met by surrounding the foot with 
a strip of adhesive plaster in such a manner as partly 
to correct deformity, the improved position being 
secured by making firm traction on the long end of 
the plaster and attaching it to the outer side of the 
leg. This method was advocated in 1850 by Dr. S. 
D. Gross, at that time one of the faculty of the New 
York University. The same material had, however, 
been used, although in a different way, many years 
before in the treatment of this affection. In 1740 
Mr. Cheselden wrote : " The first knowledge I had 
of a cure of this disease was from a professed bone- 
setter. I recommended the patient to him, not 
knowing how to cure him myself. His way was by 
holding the foot as near the natural position as he 



CONGENITAL CLUB-FOOT. 9 

could and then rolling it up with strips of sticking 
plaster, which he repeated from time to time as he 
saw occasion, until the limb was restored to a normal 
position." In orthopaedic practice the material or 
method is often of less importance than the skill and 
enthusiasm of the physician. If he has invented or 
improved an instrument, the attendants of the pa- 
tient, inspired by his confidence, unite with him in 
overcoming the inconvenience and trouble insepa- 
rable from mechanical treatment and thus succeed 
where others meet with disappointment. 

TREATMENT AT A LATER STAGE. 

When the patient, with his foot now in good shape, 
learns to walk a critical stage of treatment begins. 
If left to itself the foot will relapse at once tinder the 
weight of the body, which develops a distinct bound- 
ary plane dividing varus from valgus as the foot 
presses the ground. By way of illustration, place the 
ulnar border of the hand on a table and it will be 
seen that pressure, with alternations of pronation and 
supination, will in turn produce full pronation, cor- 
responding with valgus in the foot, and full supina- 
tion, corresponding with varus. Applying pressure 
equal to twenty-five pounds brings to light the fact 
that the weight of a child will, if properly directed, 
insure a normal foot, or if misdirected confirm de- 



10 



GROWTH AND DEFORMITY. 



formity. Advantage of this may be taken by the 
use of a brace that holds the foot, even a little, on 
the right side of the plane between varus and valgus. 





Fig. io.— Flexible Para- 
lytic Club-foot of the 
Patient seen in Fig. 17 

(P- 14). 



Fig. ir. — Brace for Foot 
shown in Fig. 10. 



The child may thus, with increasing weight and ac- 
tivity, achieve recovery by stamping the foot straight. 
Fig. 10 shows the deformed but flexible foot of a 
child four years old. The brace used in this case is 
shown in Fig. n. Its weight is thirteen ounces. It 
is made of soft steel and has a band, an upright, and 



CONGENITAL CLUB-FOOT. u 

a foot-piece composed of a tread and a riser. The 
foot-piece is lined with adhesive plaster to prevent 
rust and a piece of truss leather fastened with two 
copper rivets. More or less valgous in shape, the 
instrument makes pressure on the outer side of the 
ankle, while counter-pressure on the inner side is 
found at the upper part of the brace and along the 
riser of the foot-piece. The sole of the foot finds on 
the tread an inclined surface like that of the inner 
side of the sole of a shoe whose outer border has 
been thickened in order to precipitate valgus, an 
effect which is seen in Fig. 12. This 
favors the leverage by which the foot 
is held on the right side of the plane. 

Dr. Cook ingeniously sought to 
combat varus by providing the sole of 
a common shoe with an ample steel 
extension directed outward in order 
to reduce deformity with the descent 
of the body, in imitation of the method 
by which quadrupedal gait is modified 
by the application of a horseshoe forged 
with a lateral or antero-posterior ex- 

Fig. 12. — Tread 

tension. His experience proved that of Brace with the 
such an application would probably be effect of a Built " 

. . . up Sole (1S92). 

more effective in club-foot if a coali- 
tion were practicable between the foot and shoe, such 
as is found in veterinary practice. 




12 GROWTH AND DEFORMITY. 

The upright of the brace may be inclined back- 
ward ten or fifteen degrees with a corresponding ex- 
tension of the foot. This increases the length of the 
lever applied against deformity. Thus arranged, the 
tread will cut the sole of the shoe, which may be pro- 
tected by a steel in-sole (about an inch wide) lying be- 
tween the brace and the shoe, or else cut to fit the an- 
terior part of the sole and fastened inside the shoe by 
a screw. The strap which spans the front of the leg 
carries a sliding pad to allay the friction transferred 

to this point from the toe, 
as in the treatment of talipes 
calcaneus (p. 47). This ar- 
rangement is otherwise use- 
ful in relieving the front part 
of the foot from part of the 
weight of the body, which 
seriously interferes with the 
correction of deformity. It also seems to have an en- 
tirely unexpected tendency to lengthen the heel cord. 
The action of the brace may be improved by the 
use of adhesive plaster applied as in Fig. 13, a strip 
encircling the foot and buckled to the riser at A ; or 
a window, D, may be cut in the junction of the tread 
and riser, as seen in Fig. 14, through which the plas- 
ter C, passes to the buckle F, on the under side of 
the tread. The plaster may be conveniently doubled, 
as at A in Fig. 15, the remainder of the facing, B y 



// 
if 
1 ( 

\V 


/ r 
/ / 
/ / 

y / 

*Z*' 

J 


» 

• 

• 
'• A 


Fig. 13 


— Adhesive Strip 


Ap- 


plied 


to Untwist Anterior 


Part of Foot (1887). 





CONGENITA L CL ( T B-FOO T. 



i3 



being removed at the time of application. The pre- 
hension and traction made by this material admir- 
ably imitate the action of the hand, making pressure 




Fig. 14. — Window for Exit of Adhesive Strip 

in the selected directions, untwisting the anterior 
part of the foot and keeping the toes from surmount- 
ing the riser. 

Fig. 16 shows the brace applied to the foot, and 
Fig. 17 the child equipped for stamping her foot 
straight, increasing activity and weight and juvenile 
growth combining to secure a good result. Applied 




Adhesive Strip Ready for Application. 



under or over the stocking, the brace is worn incon- 
spicuously and without inconvenience for many 
months, a larger one being made when required by 



14 



GROWTH AND DEFORMITY. 



the patient's growth, which being rapid at this age is 
a welcome ally. By the end of the fifth year a child 
has doubled his original length, an increment that 
has perforce a positive effect for benefit or injury. 





Fig. i 6 — Brace seen in Fig. n, 
Applied to Foot seen in Fig. 10. 



Fig. 17. — Brace Applied 
and Foot Dressed. 



Nothing especial is needed in the way of shoes, the 
mate of the other shoe answering every purpose. If 
necessary the capacity of the shoe may be increased 
by cutting it down in front and adding more eyelet 
holes. With this instrument treatment may be con- 
cluded. The result should be normal ability, prac- 



CONGENITAL CLUB-FOOT. 15 

tically not impaired by a heel cord somewhat shorter 
than normal. This tendon with the other fibrous 
structures would doubtless yield to direct me- 
chanical treatment, but it is found to adapt its 
length to the requirements of walking and run- 
ning without especial attention in the course of 
treatment. 

Inversion, commonly seen at an early stage, may 
not cause anxiety as it takes place at the hip, and 
disappears under instruction when the child learns, 
in due time, the necessity of making a good appear- 
ance. Parental impatience sometimes leads to ces- 
sation of treatment after the brace has been worn 
for several months with apparently full recovery; 
but when a relapse to varus is indicated by the re- 
appearance of a callus and the rapid wearing through 
of the outer border of the sole of the shoe, treatment 
is necessarily resumed for another period. Success 
implies perhaps uncommon intelligence in the par- 
ents, who should possess the difficult quality of pa- 
tience and be able to give appreciative attention to 
the case at home. On the other hand the surgeon 
has no easy task who makes the frequent necessary 
mechanical adjustments and cannot escape ultimate 
responsibility for the home management. 

The Club-foot of Spastic Contraction. — Correction 
of deformity by the weight of the body properly di- 
rected is illustrated in the equino-varus seen in a case 



16 GROWTH AND DEFORMITY. 

of spastic contraction. The muscles being readily 
overcome by continuous leverage, the corporal 
weight holds the foot in the normal position, which 
continues when the brace is laid aside after a period 
of treatment in which growth has made some prog- 
ress. A patient thus aided to walk enjoys a general 
improvement which seems to react favorably on the 
nervous disorder. 



NEGLECTED, RELAPSED, AND INVETERATE 
CLUB-FOOT. 

While it is thus easy to remedy congenital club- 
foot when taken early and treated systematically 
there is great difficulty in the restoration of neg- 
lected, relapsed, or inveterate cases, of either con- 
genital or acquired origin. Operative treatment is 
necessary in nearly every case of this kind, and judg- 
ment will be required lest an improvement in ap- 
pearance is gained at the expense of locomotor 
ability, which is good in many cases even of severe 
deformity. Bradford and Lovett's treatise records 
the surprising locomotor skill and agility acquired in 
certain cases in which deformity had gone uncor- 
rected. A moderately severe resistant club-foot is 
seen in Fig. 18. In such a case the application of a 
brace which forcibly holds the varus partly corrected 
gives excellent ability in walking and running, and is 



CONGEXITAL CLUB-FOOT. i; 

often and very excusably preferred by the youthful 
patient to an operation which would lessen the 
strength and ability of the foot, although improving 
its appearance. Worn in this way the brace is a 
purely prosthetic appliance. Its effect 
would, however, be therapeutic and ul- 
timately curative if the patient could 
be induced to relieve the foot from the 
weight of the body by wearing in ad- 
dition a pair of crutches or an ischiatic 
support for the time necessary to bring 
the foot around to that position in which 
the weight of the body would assist in 
completing the reduction of the de- 
formity. It is of course far better to , 

J FlG. iS.— Resis- 

foresee these troubles in the very early tant Paralytic 
youth of the patient when complete res- ( l lub ; foot ' Age 

J *■ t len ^ ears. 

toration is easily practicable. 

Double Club-foot, — The recumbent position is nec- 
essary if the affection is double, unless one limb be 
treated at a time, in which case— as when only one 
foot is affected — resort may be had to crutches, or, 
better, to ischiatic support, with a high sole under 
the other foot, as in hip or knee disease, until the 
straightening of the brace and the foot and contin- 
uous leverage lead the way to the vantage-ground 
where the weight of the body may be enlisted as a 
corrective force. 




i8 



GROWTH AND DEFORMITY. 



Subcutaneous Tenotomy.— If the tendo Achillis 
fails to meet the requirements of locomotion after 
reduction of deformity by this method, as a last re- 




Fig. ig. 



maining defect it may be divided. In 1831 Dr.Stro- 
meyer (1804-76) made his first section of this tendon, 
an operation which has been said to " mark the 
beginning of the whole system of subcutaneous sur- 



CONGENITAL CL ( 'Il-FOOT. 



19 



gery and of all really successful orthopaedic treat- 
ment." Five years later Dr. Little (1810-94) visited 
Stromeyer and against the advice of friendly medi- 




Fig. 20. 



cal authority submitted to tenotomy for talipes equi- 
no-varus (left), following an attack of infantile paraly- 
sis at the age of four years. The result in this and 
other cases " caused a revulsion of feeling in favor of 
subcutaneous tenotomy/' which was first performed in 



20 



GROWTH AND DEFORMITY. 



England by Dr. Little himself in 1837. In that year 
Dr. Detmold (1808-94), coming to New York, " intro- 
duced orthopaedic surgery into America," making one 
hundred and eighty divisions of the heel cord in two 




Fig. 21. 



years. In current medical opinion Stromeyer is 
credited with the discovery of subcutaneous te- 
notomy, Little with having widely disseminated a 
knowledge of it, and Detmold with its introduction 



CONGENITAL CLUB-FOOT. 21 

into this country. Not a few of the advances of sur- 
gery have been due to previous misconceptions oi 
the danger of invading certain regions or wounding 
certain tissues. Stromeyer's discovery greatly en- 
couraged the study and practice of orthopaedic sur- 
gery. With further advances in general medicine and 
surgery it is probable that other changes of mental 
attitude will be seen and other modifications will be 
accepted in the methods of this branch of practice. 

The Goniometer. — The flexion of the foot on the 
leg may be conveniently measured by the goni- 
ometer. With the knee flexed in order to relax the 
gastrocnemii and the tendo Achillis, and the foot 
held midway between varus and valgus, one arm of 
the instrument may be held parallel with the crest 
of the tibia, and the other with the plantar surfaces 
of the heel and the ball of the foot. The degrees of 
flexion may then be read on the scale. After club- 
foot it is difficult without impairing the power of the 
limb to give to the heel cord the length which nor- 
mally permits flexion of fifty or sixty degrees. But 
flexion of twenty or twenty-five degrees, which is ac- 
quired in the course of routine treatment, practically 
secures full ability without defect of gait. 

Case I. — Double Congenital Club-foot. — Without 
previous attention, treatment was begun September 
5th, 1896, at the age of three months, the shape of the 
boy's feet at that age being seen in Fig. 22, which 



22 



GROWTH AND DEFORMITY. 



also shows the progress made in the case until the 
child was five years old. The natural increase in 
size was clearly an important element in correction. 




Fig. 22. — Case I. Reduction Begun by Leverage, Promoted by the Favor- 
able Action of the Weight of Body, and Aided by Growth. 

The outlines were grouped and reduced en bloc in 
the camera and were thus made to present their rela- 
tive proportions. The first stage of treatment occu- 
pied twelve months, in which forty-three visits were 
made to the office. The appearance and lateral 
flexibility being normal, treatment was then sus- 



CONGENITAL C L ( r B-FOOT. 



23 



pended. At the end of five months, in which noth- 
ing was done, the child had learned to walk, and it 
was noticed that the outer borders of the soles were 
becoming callous. Braces were therefore applied 
like the one seen in Fig. n, larger ones being sub- 
stituted as the child grew. In this stage forty-two 
visits were made in twenty-two months, and treat- 




FlG. 23.— Case I., Corrected Double Congenital Club-foot. Age of 
patient, seven years. 



ment finally ceased when the patient was four years 
old. A year later the last outlines seen in Fig. 22 
were taken. At that time the left ankle was flexible 



24 



GROWTH AND DEFORMITY. 



twenty-five degrees, and the right thirty degrees. 
When walking or running the boy had no defect in 
his gait. Two years later calluses were absent and 




Fig. 24. — Case I., Corrected Double Congenital Club-foot. 

the toes were not inverted in walking. The limbs are 
seen in Figs. 23, 24, and 25. He was doing what other 
boys of his age do, with no indication that his feet had 
ever required especial attention. 

An operation is often a desirable resort in club- 
foot. Some visits to the physician may thus be 
escaped. The statement that to operate for club- 
foot is a confession of failure is too sweeping. Oper- 



CONGENITAL CLUB-FOOT. 25 

ations must, however, be supplemented by mechani- 
cal treatment. 

A general view of the subject shows that congeni- 
tal club-foot, being an affection easily responsive to 
treatment, is as a rule well and promptly corrected 
by the method and with the instruments and mate- 
rials most conveniently under the control of the phy- 
sician responsible for the case. To insure sue 




Fu 



-Case I.. Standing with Toes Raised. 



however, all expectation of a speedy cure should be 
frankly abandoned at the outset, and preparation 
made for dilieent treatment be^un soon after birth 



26 GROWTH AND DEFORMITY. 

and continued until growth is well advanced. Bet- 
ter results are reached by patiently relying on slow 
methods and natural growth than by resorting to 
forcible correction repeated whenever the deformity 
becomes offensive through neglect. There is, more- 
over, one source of disappointment which should be 
borne in mind, and that is the idea that wearing a 
brace is all that is necessary. A brace in itself is 
entirely inefficient. It must accomplish a constant 
definite purpose, which it can be made to do only by 
the presence and alertness of an intelligent mind. 
The most faithful and anxious parent requires fre- 
quent advice and supervision, not to mention the 
readjustments and alterations of apparatus repeated- 
ly required with the lapse of time and changes in the 
foot. In the history of a case thus managed there 
will be intervals of considerable length, when treat- 
ment may be suspended, to be resumed with the first 
sign of returning deformity. 

FLAT-FOOT. 

The human foot, for many reasons, does its work 
at a disadvantage. The corporal weight falls on two, 
instead of four, pedal extremities, as in some other 
animals. The delicate and complicated construction 
of the feet and the small floor area which they oc- 
cupy seem out of proportion to their duty of support- 



FLAT-FOOT. 27 

ing the towering frame above them, in some < 
not unlike a pyramid on its apex. The carrying of 
such a load is a menace to these overburdened mem- 
bers, and when a prolonged effort is made under addi- 
tional weight, as by a native carrier in strange lands 
or an armed soldier on a forced march, the endurance 
of the feet excites wonder. With the common ail- 
ments, such as corns, bunions, chilblains, blisters, 
ingrowing nails, hammer tots, hallux valgus, Mor- 
ton's toe, perforating ulcers, weak ankle, loss of the 
arch, bursitis and osteitis, the foot seems destined for 
disability soon after the journey of life is begun and 
certainly when the pilgrim takes on the fat that 
goes with age and good living. It was a profane re- 
mark of Savarih, the great gourmand, that among 
the works of creation the design of the human foot 
was a conspicuous failure. It is sufficiently evident 
to the student that only a consummate adaptation of 
mechanics has enabled this discredited member to 
perform its superlative functions. He should there- 
fore undertake its reconstruction only after a good 
deal of hesitation. The treatment of disabled and 
deformed feet is indeed beset with difficulty, espe- 
cially if undertaken while the feet are in use. 

One of the common ailments is impairment or loss 
of the arch, deforming the foot, but less serious as a 
deformity than as a painful disability. It is caused 
evidently by overuse or a failure to appreciate until 



28 GROWTH AND DEFORMITY. 

too late the fact that machinery of this kind has a 
limit of endurance. The beginning of the trouble is 
insidious, pain resembling that of rheumatism shift- 
ing and visiting different parts of the foot and leg, 
and accompanied by a gradual depression of the arch, 
one foot preceding the other on the downward road. 
Periods of rest are followed by relief from pain, but 
a return to work recalls the trouble. After a few 
months or years of misery the feet become truly flat 
and are useful and painless for the rest of life, the 
related and coordinating structures having gradually 
become adapted to each other and to the abnormal 
state of affairs. Waiters, chambermaids, and sales- 
men become footsore from too much standing and 
walking. In hospitals it is a common affection 
among nurses who have not before been much on 
their feet. Rapid growth and a sudden increase in 
flesh are contributing causes. The trouble attacks 
bartenders whose hours are long and who wear thick 
soles on beer-soaked floors, and it is said to be com- 
mon in boys who follow the plough through soft soil 
in heavy boots. 

Direct reinforcement of the arch by an upward 
curving in-sole is naturally the first suggestion in the 
way of treatment. This requires, however, very skil- 
ful and exact adjustment, since a great and active 
burden must be supported by a comparatively slight 
substructure. Many cases will probably be better 



FLAT-FOOT. 29 

managed indirectly, as by a change to some occupa- 
tion requiring less work from the feet. As this is 
seldom convenient, relief may be sought by taking 
advantage of heretofore neglected opportunities to 
sit, avoiding unnecessary walking in the intervals of 
work, and by other means of sparing the feet which 
will occur to the mind with an acquired knowledge 
of the threatening peril. An interesting observation 
is that when a patient's attention is called to the 
point he finds it easier to walk up a moderately in- 
clined path than down, showing that a desirable po- 
sition is that of flexion of the foot on the leg, which 
may be promoted by lessening or removing the heel 
of the shoe. In other ways also the shoes may be 
improved. The sole should be very flexible and the 
ankles left free from constriction. A common 
method of strengthening the foot by tightly lacing 
the shoe around and above the ankle should be 
omitted as a vain attempt to support impending 
weight by inadequate means. 

Shoes made especially for the support of the ankle 
are useless in any case, and especially for the feet of 
a growing child. It is better to avoid undue fatigue 
and to look for natural development of strength and 
stability by moderate exercise of the feet and ankles 
unsupported. Constriction of the ankle cannot but 
impair the efficiency of the muscles of the leg, which 
control the multiform motions of the foot through a 



30 GROWTH AND DEFORMITY. 

complex system of tendons, the direction of which is 
changed by turning the corner of the ankle. When 
restraints are removed from the ankle, and especially 
when shoes, large and comfortable in other respects, 
are prescribed for flat-feet, the first result will prob- 
ably be an increase of pain in locomotion, which 
should be expected after a sudden change of this 
kind. If the first pain and inconvenience are en- 
dured they cease after a time and give way to unex- 
pected comfort and surprising ability in walking. 
The patient has been doing the wrong thing for a 
long time, and may not expect a sudden and painless 
return to the path of rectitude. He may be exhorted 
in the words of Dr. Fayette Taylor, who was wont 
to say that one could not go up hill any quicker than 
he went down. 

Locomotion in a painful stage is facilitated by 
transferring weight from the toe to the heel. This 
is inferred from the fact that comfort comes with 
removal of the heel from the shoe, which produces 
flexion of the foot on the leg, an attitude in which 
the heel is thrust down toward, and the toe with- 
drawn upward from, the ground. It is well, therefore, 
to relieve pain by leaning a little backward in stand- 
ing and walking, which moves a part of the weight 
from the arch to the heel. It may not be possible in 
many cases to restore the lost arch, but by a resort 
to timely rest and minor devices, commonplace but 



FLAT-FOOT. 31 

effective, comfort and ability in walking may be as- 
sured. 

Minor Afflictions of the Feet. — Flat-foot is an ail- 
ment for which there is really no good excuse. For 
the results of joint disease, or of infantile paral; 
the patient may not justly be held accountable, but 
with prudence and intelligence he should escape 
breaking down or wear- ^^ 

ing out of the feet. He ( J 



should also be held to s~\ f~*\ (^\ ( j 

account for other com- ^^ ^ — ' 

mon ailments Mich as ^_^^ #***% 

ingrowing nails, ham- \J \^J \^J: r "( )\( 




mer toes, hallux valgus, 

and corns. FlG " ^T^?™? " f 

by Adhesive Plaster (1887). 

The latter affliction 
may be eliminated by maceration at stated intervals, 
in a tepid saponic solution, and removal o\ extra- 
neous epidermis by erasion. If this domestic pro- 
cedure is repeated only when pain becomes intol- 
erable, the trouble will recur interminably through 
moderate pressure concentrated on underlying bony 
processes. 

Hammer toes result from overcrowding the digits 
in tight shoes. This ill may be relieved by amputa- 
tion of the rampant toe through its metatarsal bone, 
an operation sometimes practised, it is said, on the 
second digit of a normal foot in the search for cos- 



32 GROWTH AND DEFORMITY. 

metic effects. Reduction may be assisted by the 
application of a narrow piece of plaster, as in Fig. 
26, which readily corrects overlapping during the 
time of growth. 

Ingrowing nails are caused by thoughtless rupture 
of a modus vivendz, in which the nail preempts a 
nidus, and the callous skin, as the result of long cus- 
tom, tolerates the lateral edges and corners of the 
nail, which should never be retrenched except by 
a "bang" stroke, made at right angles with the axis 
of the phalanx. Relief in the worst cases surely fol- 
lows the necessarily slow restoration of the modus 
■vivendi referred to. 



CHAPTER II. 

DEFORMITIES AND DISABILITIES CAUSED BY 
INFANTILE PARALYSIS. 

When the eighteen months (which are said to be 
the limit of spontaneous recovery from anterior polio- 
myelitis) have passed, the affected muscles are found 
to be paralyzed at a critical time in the child's his- 
tory, when the development of the joints of the 
lower limbs is especially rapid under the incitement 
and exertion of learning to walk. Although walking 
is a commonplace act and receives but little atten- 
tion, it is really a difficult feat learned only after long' 
and laborious practice, in which the will commits the 
machinery of locomotion almost entirely to reflex 
control. 

Comparative Exemption of the Upper Limbs. — It is 
in the lower extremities that the deformities and dis- 
abilities caused by this form of paralysis are con- 
spicuous. They rarely attract attention in the upper 
limbs. It is not necessary to explain this fact by 
the supposition that the affection has a preference 
for the nervous filaments supplying the lower extrem- 
ity. A probable explanation is offered in the propo- 
sition that sufficient power is gained in the upper 
3 33 



34 GROWTH AND DEFORMITY. 

extremity and not in the lower, because in the former 
the muscles can advance from small to great efforts, 
gaining power gradually by increasing use, while in 
the latter, where there is failure at the outset to con- 
trol the weight of the body, the fibres miss the very 
beginning of development. It has been held that 
assistance given gradually to muscles thus affected is 
an incitement to recovery of power. Possibly a post- 
ponement of the erect position and a series of grad- 
uated exercises enforced through the period of early 
growth might measurably restore muscular power 
and avert some of the threatening locomotor dis- 
ability. 

PARALYSIS OF THE ANTERIOR MUSCLES 
OF THE THIGH. 

Occurring as an epidemic in the hot season, infan- 
tile paralysis is seldom recognized until the fever 
subsides and certain groups of muscles are found to 
have lost their motor innervation. Affecting the 
muscles of the thigh, it entails a miserable defect in 
the gait. If the quadriceps extensor is paralyzed the 
foot cannot be held out by an extension of the knee 
when the patient is sitting, and in walking he is apt 
to put a hand on the lower part of the thigh to keep 
the limb from flexing and causing a fall. If the 
treatment of such a case is neglected or postponed 
the child takes a crutch, and when the paralysis is 



INFANTILE PARALYSIS. 35 

well marked the whole leg is consigned to disuse and 
atrophy. The other parts of the limb may be useful 
and strong, but weakness at this point, like the re- 
moval of the keystone from an arch, demolishes the 
whole structure. Disuse leads to poor circulation, 
the limb hangs useless against the crutch, it suffers 
from cold, and in various ways is such an annoyance 
that in later years amputation is not uncommonly 
a welcome resort. Sometimes the attenuated thigh 
and leg are bound together to form a stump for an 
artificial limb. 

Treatment. — The obvious remedy lies in mechani- 
cal reinforcement coincident with growth for the 
purpose of lessening present disability and encourag- 
ing local and general functional development, the 
recompense being future unaided locomotion with 
the broad coaptated surfaces of a hyperextended 
joint. The points of pressure and counter-pressure 
required in such a case are indicated by the arrows 
in Figs. 27 and 28. A brace applied in the case of a 
child weighed one pound and two ounces. 

Counter-pressure is made at the lower end of the 
brace by a heel cup formed by webbing riveted to 
the upright and to the border of the tread, in the 
manner shown in Fig. 40, p. 48, and this in many 
cases is the only piece of webbing in the whole ap- 
paratus. The upright may occupy the inner or the 
outer side of the limb, according as the condition of 



36 



GRO WTH AND DEFORMITY 



the foot requires buckles and straps for opposing 
varus or valgus. Aside from these no attachments 
are needed, the splint being held in place by the steel 




\ \ 




Fig. 27. Fig. 28. 

Figs. 27, 28. — Points of Pressure and Counter-pressure in Paralysis of An- 
terior Muscles of the Thigh (1888). 

bands which half encircle the limb; their tractable 
steel should be so curved that when the splint is 
looked through endwise the lumen formed by the 
steel bands should not much exceed the antero-pos- 
terior diameter of the shaft of the femur. To pre- 
vent rust the steel may be wound with adhesive 
strips and some convenient renewable fabric. The 
stocking will intervene between the skin and the 



INFANT I L E PA RA L YSIS. 



37 



lower part of the brace, the foot-piece being lined as 
that of a brace for club-foot. The chief pressure 
falls on two points of the thigh, an upper posterior 
and a lower anterior point; but pads and wadding, 
as in all orthopaedic apparatus, are better avoided as 
far as is possible. With a knee 
stiffened in this way, and a limb 
perhaps otherwise defective in in- 
nervation, walking will be far from 
graceful. The gait will, however, 
be strong and effective, and the 
patient will be gratified by his abil- 
ity to walk a longer distance and 
faster than before. In cases of 
this kind every additional gain in 
power is highly valued. When 
sitting becomes inconvenient from 
increasing length of limb in a grow- 
ing patient a joint may be intro- 
duced at the level of the knee, as 
in Fig. 29, with automatic fixation, 
alternating with voluntary release, 
as shown in Fig. 30. A brace ap- 
plied in the case of a very heavy patient weighs three 
pounds and eight ounces. It gives firmness to the 
gait and an ability to flex the knee at will. Women 
thus equipped have been enabled to assume the de- 
votional duties of monastic life. 




Fig. 29. — Brace with 
Joint at the Knee. 



38 GROWTH AND DEFORMITY. 

Two forms of "release" are seen in Figs. 31 and 
32, the "bucket" and the "lever." A "fall joint," 




Fig. 30. — Brace Flexed. 

in which a tube or hood slides down the upright oyer 
the joint is probably more easily made, but in order 



Q> <2> 




Fig. 31. — Details of " Bucket Release." 

to allow the " fall " to be raised far enough to clear 
the joint the steel band must occupy a level where it 



TALIPES CALCANEUS. 39 

is less effective in keeping the knee extended. If 
both of the lower limbs are paralyzed, the patient 
creeps or relies on a bearer or a wheel-chair. In 




m 



w — I 



FlG. 32. — Details of " Lever Release.'' 

such a case the application of a brace to each limb 
renders locomotion with the further aid of a pair of 
crutches entirely practicable, as is illustrated in Case 
IV. (p. 57). 

TALIPES CALCANEUS. 

Paralysis of the fibres which move the tendo 
Achillis causes a very serious locomotor disability, 
but one easily overcome by mechanical means. 
When the action of the heel cord is eliminated the 
patient cannot stand on tiptoe and his weight is 
necessarily concentrated on the heel. The result is 
talipes calcaneus, which implies an unimportant de- 
formity, but entails a serious disability in which the 
anterior part of the foot is entirely useless. The 
limb in locomotion is reduced to the condition of a 
peg leg. It is an example of non-deforming chid- 



40 GROWTH AND DEFORMITY. 

Joot. The term club-foot is rather loosely applied to 
all the varieties of talipes. It might well be limited 
to varus, which reduces the foot to the appearance 
of a wooden club. The other varieties (valgus, equi- 
nus, and calcaneus) are attended by disability rather 
than deformity. An extreme case of calcaneus, 
however, presents a remarkable deformity with its 
magnified heel and insignificant toe, features which 
are quite invisible when the foot is dressed. Ac- 
quired, or paralytic, calcaneus is readily mistaken 
in the very young for congenital calcaneus, which 
is of extremely rare occurrence. An example pre- 
senting the resistance of congenital equino-varus 
would be well worth a careful description. The few 
cases reported have yielded to little treatment or 
spontaneously even before the treatment proposed 
could be applied. In an ordinary case of paralytic 
calcaneus hopeless elongation of the heel cord soon 
appears. Sanguine confidence in reconstructive sur- 
gery has led to division and shortening of the tendon 
by sutures ; but its elongation, being the result of 
sheer inability to sustain weight, may be expected 
promptly to recur after such an operation. The con- 
dition in talipes calcaneus resembles that caused by 
amputation at the tarso-metatarsal junction, which 
was rudely performed by the American aborigines 
when they wished to prevent the escape of a captive 
slave. 



TALIPES CALCANEUS. 



4i 



"The Human Wheel." — In an ingenious analysis of 
human locomotion, Dr. Holmes wrote: " Walking is 
a perpetual falling with a perpetual recovery. Man 
is a wheel with two spokes, his legs, and two frag- 
ments of a tire, his feet. He rolls necessarily on 
each of these fragments from the heel to the toe. If 




FIG. 33- — " The Human Wheel " (O. W. Holmes, 1863). 



he had spokes enough he would go round and round 
as the boys do when they ' make a wheel ' with their 
four limbs for its spokes. But having only two 
available for ordinary locomotion, each of them has 
to be taken up as soon as it is used and carried for- 
ward to be used again, and so alternately with the 
pair." Observation of the gait of a patient crip- 
pled by this form of paralysis shows that some 
of the felloes are absent from the human wheel. 



42 



GROWTH AND DEFORMITY. 



The result is irregular locomotion or jolting pro= 
gression. 

The Strain on the Tendo Achillis. — An obvious func- 
tion of this tendon is to support the body on tip- 




Fig. 34. — Demonstration of Adverse Lever at Ankle-joint. First Position, 
in which the Strain on the Tendo Achillis Equals the Weight of the Body. 



TA L I PES CA L CA A E I S 



43 



toe. The extravagant size of the muscles found in 
the calf is accounted for by the fact that they do 
their very exceptional work at the great disadvan- 




FlG. 35. — Second Position, in which the Strain on Tendon is Trebled 

(1S90). 



44 



GROWTH AND DEFORMITY. 



tage of a remarkable adverse lever at the ankle-joint. 
The strain falling on the heel cord may be appre- 
ciated experimentally by a device which shows that 
treble the weight of the body represents the tension 
on the tendo Achillis. In Figs. 34 and 35 the weight 
of the body is represented by a four-pound bag of 
shot. The machine being held on a table, the bal- 
ance is seen to vary in its registry when the joint 
representing the ankle is moved to different points 
between the heel and toe. When the joint is near 
the toe a small fraction of a pound is registered, but 
when it is near the heel the index points to twenty 
pounds or twenty-four pounds. In Fig. 34 the ankle 




Fig. 



36. — Relation of the Joint to the Tendo Achillis and the Toe 
(Marshall, 1863). 



is midway and the balance reads four pounds, show- 
ing that if the ankle were at this point, the strain on 
the tendon would be that of the weight of the body. 
In Fig. 35 the joint is three inches from the heel and 
nine inches from the toe, which approximates its 



TALIPES CALCANEUS. 45 

relative position in the foot as shown in Fig. 36. In 
this position the scale reads twelve pounds, or three 
times the weight of the shot, demonstrating that if 
a boy weighs one hundred 
pounds, the tiptoe strain on 
his tendo Achillis is three 
hundred pounds. Practical- 
ly the strain is often greater, 
being the sum of weight 
plus momentum. The lever 
present is of the second 
order, in which the weight 
is between the power and 
fulcrum as seen in Fig. 37, 
where the forces in equilib- 
rium about the fulcrum, C, P 

are the Upward tension of the ^^.-Mathematical Demon- 

stration ( 1S90). 

heel cord, T, and the down- 
ward pressure of the tibia, D B, at B, represented by 
R. The moments being equal, T X AC = R X B C. 
As R is the resultant of the tension of the heel cord 
and the resistance of the ground at C, equal to the 
weight of the body, represented by W, R = T+ W. 
Therefore T X AC = (T + W) BC, or T X AC = T 
xBC-f W x BC, or TxAC-TxBC = Wx 
BC. But AC - BC = AB. Therefore T x AB = 
W x BC 




W x BC, or T 



A B 



If now the weieht of 



46 



GROWTH AND DEFORMITY. 



the body is one hundred and fifty pounds, and the 
distance from the ankle to the toe six inches and that 
from the ankle to the heel three inches, the tension 



is 



— or — , or three hundred pounds. Dr. Wirt 

3 3 

reached practically the same conclusion by the use 
of cosines. 

Very little deformity is produced by either an 
elongated or a shortened heel cord. But in their 
effect on locomotor ability they are widely different. 
A short tendon, unless it is ex- 
cessively short, causes no lame- 
ness. It does not prevent a per- 
fect gait and prolonged exertion 
in dancing or on a march, and 
it may be useful in maintaining 
the equine foot when factitious 
length is desired for a shortened 
limb. Dr. Hibbs has made an 
important study of a series of 
cases in which subcutaneous divi- 
sion of the tendon had seriously 
affected its relation to the mus- 
cles of the calf. Civilized man 
assumes few positions which are 
interfered with by a moderately short tendo Achillis, 
while a lengthened tendon urgently demands com- 
pensation. This may conveniently be found in the 




Fig. 38. — Brace used 
in Case II., Talipes 
Calcaneus (1890). 



TALIPES CALCANEUS. 



47 



application of a brace such as is shown in Figs. 38. 
39, and 40. 

Treatment. — The steel band at the upper part of 
the brace gives attachment to buckles which receive 
a strap against which the 
patient kneels when 
throwing his weight on 
the brace. When rising 
on his toe he has a com- 
posite sensation of stand- 
ing and kneeling. The 
pressure of kneeling is 
felt near the tubercle of 
the tibia, and to this point 
is transferred the callou> 
condition of the ball of 
the foot, and here fre- 
quently is found an 
adventitious bursa of con- 
siderable size. A verti- 
cal upright affords relief, 
but a better effect may 
be obtained by inclining 
it backward experimentally until the inclination is 
found at which walking is most easily done. Such a 
brace cannot of course furnish the active power which 
the muscles of the calf exhibit in running and jump- 
ing, but it gives sustaining power to the anterior part 




Fig. 39. — A Later Brace (1S9S). 



4 8 



GROWTH AND DEFORMITY. 



of the foot and restores normal walking, in which the 
patient rolls from the heel to the toe. The upright 
may readily be inclined backward by bending the 

foot-piece downward when it 
is a simple tread without a 
riser, as shown in Figs. 39 
and 40. These braces weigh 
two pounds three ounces and 
one pound three ounces. 
They are worn by an adult 
and a child respectively. If, 
however, calcaneus is compli- 
cated with lateral deviation, 
the riser necessary for the cor- 
rection of varus or valgus pre- 
vents bending of the tread, 
and the upright of such a 
brace as is seen in Fig. 41 
may then be bent by experi- 
mental blows with a heavy hammer until the proper 
angle is found, and in subsequent braces a straight up- 
right may be set at the determined angle. A joint 
at the ankle is unnecessary. It adds to the cost, 
is useless, and soon wears out under the rapidly re- 
peated blows which attend locomotion. The brace is 
worn over a stocking for comfort and under another 
stocking for concealment. Worn during adoles- 
cence, such an apparatus abolishes present lameness 




■Fig. 40. — A More Recent 
Brace in which the Up- 
right and Tread are of 
One Piece (1902) . 



TALIPES CALCANEUS. 



49 



and lessens cavus in after-life. It secures remark- 
able excellence in walking, whatever may be the 
hypertrophy of the heel and the atrophy of the ante- 
rior part of the foot. 

Case II. — Right Talipes Calcaneus. — In 1879, a 
girl eleven years old had been lame for several years 
following an attack of " worm fever." She had char- 
acteristic inability to stand on tiptoe with the affected 
foot, an enlarged heel, and a wasted limb. The 
brace seen in Fig. 38, weighing one pound and eight 
ounces, restored ability to use the anterior part of the 




Fig. 41. — Case II., Standing Tiptoe with Help of Brace (1SS5). 

foot, and corrected asymmetry of gait. An instan- 
taneous photograph, taken in 1885, is copied in Fig. 
41, when the affected leg, from atrophy of the mus- 
cles of the calf, was nearly three inches smaller than 
4 



50 GROWTH AND DEFORMITY. 

the well one. In 1890 she wrote that the brace main- 
tained a normal gait and was always in use out of 
doors, and when housework was to be done. 



PARALYTIC TALIPES VARUS AND VALGUS. 

Infantile paratysis is the cause of several other 
forms of disability in locomotion. If the muscles on 
one side of the leg are paralyzed, the foot turns in the 
other direction. As muscular failure is the cause of 
acquired talipes, it is necessary to understand the part 
which the muscles take in locomotion. 

Mechanics of Locomotion. — The common idea that 
the muscles push the body along is not in accordance 
with the facts. They may do so when a man climbs a 
tree or ascends a steep hill, but ordinary walking is a 
complex and yet a simple procedure in which the 
muscles do not play a very heroic part. First the body 
leans in the selected direction, then the feet swing 
forward one after the other, and the act of walking 
is completed by muscular contraction, which simply 
holds the feet steady under the weight of the advanc- 
ing body, which falls first on one foot and then on 
the other, in accordance with Dr. Holmes' view that 
walking is a perpetual falling with a perpetual recov- 
ery. Illustrations are found in the leaning figure of 
a little child just beginning to walk and in that of a 
man in alcoholic titubation. The spectators look for 



PARALYTIC VARUS. 51 

a fall which seldom comes. It may be said that the 
faster one walks the more imminent is the perpetual 
falling, and the more instantaneous the perpetual re- 
covery. Success in a race evidently depends largely 
on one's superior ability to get the feet under the 
body as it falls forward. It may not be easy to give 
up the idea that the feet and legs push the body for- 
ward. The foot certainly spurns the ground in the 
wake of the runner in a very vigorous manner, but 
the recoil of this stroke simply propels the foot for- 
ward as it hastens to receive the weight of the falling 
body. 

Talipes Varus. — With this understanding of the 
mechanics of locomotion, it is interesting to note that 
when the weight of the body falls on the limb in the 
act of walking, the muscles on all sides responding 
to a call for concerted action instantly contract by a 
common reflex impulse to. maintain the stability of 
the foot. At this crisis, if those on the outer side, 
for instance, are paralyzed and unable to obey the 
call, those on the inner side, suddenly contracting 
without opposition, throw the foot into talipes varus, 
which the weight of the body and the blows of loco- 
motion soon aggravate and which growth presently 
makes offensive and irreclaimable. 

Contrary to public opinion, cases of club-foot are 
more commonly of paralytic than of congenital origin. 
A foot deformed at birth is recognized at once. It 



52 GROWTH AND DEFORMITY. 

is apt to receive prompt attention in an early, plas- 
tic, and rapidly growing stage, when it is easily made 
to grow straight. But incipient paralytic club-foot is 
insidious. When the trouble is noticed there is sim- 
ply a defect in gait which it is hoped will be " out- 
grown." Being painless, and not severely disabling, 
it is apt to be neglected until the shortened fibres 
and misshapen bones seriously oppose restoration. 
If such a foot be taken in hand at once the bones will 
be found in normal shape and the fibrous structures 
will be relaxed. In this stage reduction is easy, the 
appearance being that of the foot seen in Fig. 10 
(see p. 10). 

Treatment may be the same as that described in 
the later stage of congenital varus. The foot should 
be held by a brace in its normal shape until growth 
and bodily weight confirm restoration (pp. 9-14). 
The treatment of congenital varus is generally re- 
warded by the full measure of success, but the result 
of treatment in a case of paralytic varus will prob- 
ably be marred by the presence of paralysis in other 
parts of the limb. Not uncommonly the brace must 
extend above the knee to reinforce the extensors of 
the leg while the varus is under correction. 

Talipes Valgus. — If the muscles on the inner side 
of the leg are paralyzed their opponents will produce 
valgus, a variety of talipes less deforming and dis- 
abling than varus, and usually overshadowed by the 



TALIPES VALGUS 



55 



concurrence of calcaneus, which is more serious in 
its effect on locomotion than valgus but fortunately 
more easily managed. Deformities of the foot simu- 
lating the effects of infantile paralysis have their 
rise in the disintegration 
which undermines the 
bones in locomotor at- 
axia. An instance of tab- 
etic valgus is shown in 
Fig. 42. The abnormal 
muscular action of Fried- 
reich's disease produces 
similar results. In these 
cases the primary affec- 
tion is so disabling, local- 
ly and generally, that me- 
chanical relief is seldom 
practicable. In favor- 
able conditions, however, 
purely prosthetic appara- 
tus is useful in giving 
stability to the ankle, lat- 
eral support in Charcot's knee, or stiffness to the 
knee, by the action of an automatic joint, prolonging 
the period in which walking is possible with the 
aid of crutches. 




Fig. 42. — Tabetic Talipes Valgus. 
Man, Thirty-five Vears Old, 
New York Hospital (1S98). 



54 GROWTH AND DEFORMITY. 

DETAILS OF TREATMENT OF PARALYTIC 
DISABILITIES. 

In persistent varus, as in all cases which require 
pressure on prominences near a joint, metallic con- 
tact should give way to webbing" under convenient ad- 
justment by buckles so distributed as to draw the 
deformed part into a recess formed by bending the 
frame of the brace. When pressure is to be made 
on the shaft of a bone, however, as in the reinforce- 
ment of the extensor femoris, illustrated in Figs. 27 
and 28 (on p. 36), the bone will be found partially 
cushioned by subcutaneous tissues, and care should 
be taken to bend and twist the steel till its whole sur- 
face of contact is evenly applied to the bony surface 
receiving the pressure. Padding and protecting wads 
do imperfectly and uncomfortably what may be bet- 
ter done by conforming the steel frame of the brace. 
As apparatus of this kind furnishes support which 
the bones fail to give, it may be likened to an outside 
skeleton, like that of a lobster or of a crab, but ap- 
plied with difficulty to the sensitive skin. In the pres- 
ence of even this hindrance a supporting apparatus 
may be so well designed and fitted as to preclude 
a demand for cushions and padding, the absence 
of which will simplify the application and make 
prominent its essential mechanical features. In a rea- 
sonable time the skin becomes callous and ceases to 



PARALYTIC DISABILITIES. 55 

resent pressure, and the patient readily accepts incon- 
venience if locomotion is made easy and effective. 
Occasional breaks in the steel show the points that 
require strengthening and prove that the brace is 
doing under strain what was intended. In some cases 
it is a good plan to have braces made in duplicate, 
so that repairs may be made without inconvenience. 
To adjust such an appliance and to keep it progres- 
sively effective during growth and the development of 
tardy muscular power require considerable time and 
attention, but otherwise the expense is not great and 
should not forbid this relief to those who in strait- 
ened circumstances stand more in nucd of it than 
others. 

The Importance of Early Treatment may be em- 
phasized by a consideration of the unhappy condition 
©f quite a number of adults who suffer from various 
degrees of lameness, some of them being so disquali- 
fied for locomotion as to require bearers and wheel- 
chairs. Treatment of a case of this kind may fail 
because of the difficulty which an adult has in ac- 
commodating himself to new restraints and sup- 
ports, things which a child does not object to and 
soon enjoys if they extend his radius of play and mis- 
chief. Some of this hesitation is reasonable and ex- 
cusable because of the time taken for defective groups 
of muscles to develop the power called for and neces- 
sary before the appliance can give increase of ability. 



56 GROWTH AND DEFORMITY. 

Neglected muscles respond rapidly to such demands 
in childhood. They may not be expected to answer 
so promptly later in life and the adult will not so 
readily endure the uncomfortable and unaccustomed 
fatigue which is the preliminary and accompaniment 
of muscular development. 

Case III. — Disability following Infantile Paraly- 
sis. — A man, 35 years old, had spent most of his 
years on crutches. His disability had received a 
great variety of treatment and mechanical attention 
at home and abroad. The anterior part of the left 
foot was useless from defective leg muscles, and the 
right limb was disabled by paralysis of the anterior 
muscles of the thigh. With these two points rein- 
forced, he would have been in a position to dispense 
with crutches, still walking, of course, with consider- 
able lameness. When a trial was made, beginning 
with a brace for the affected foot, it was seen that it 
called for the use and development of other groups 
of muscles also, in the extremity and even in the 
trunk. This would have been brought about easily 
in the case of a child, but it was too much for the 
matured muscular system of an adult, and withal 
called for such a change in the man's habits and set- 
tled beliefs as to his physical condition that the treat- 
ment, hesitatingly begun, was rather eagerly aban- 
doned. 

On the other hand, assistance of this kind offered 



PARALYTIC DISABILITIES. 57 

in childhood has in many instances favored the de- 
velopment throughout the time of growth of impor- 
tant muscular groups and has thus secured comfort 
and ability and nearly symmetrical locomotion in 
after-life. One such patient, a woman, says that mis- 
taken friends advise her to lay the heavy contrivance 
aside, but the whole muscular system having made- 
its growth in accord with the support which a part 
has received from the brace, she finds it too useful to 
be discarded. Another always wears the brace when 
in "company" in order to appear well, the absent 
muscular power having its place taken by the artifi- 
cial support, and the developed accessory muscles 
helping to complete the symmetry of locomotion. 

Case IV. — Disability following Infantile Paraly- 
sis. — A noteworthy instance is that of an apparently 
healthy boy who at the age of 14, was unable to stand 
on account of a belated attack of infantile paralysis. 
-Apparatus was applied for automatic fixation of each 
knee in the extended position, allowing him to walk 
with crutches, and voluntary release of fixation when 
he desired to flex the limbs in sitting. Thus as>i>ted 
and incited, the unused muscles in various parts of 
the body developed with exercise and the comple- 
tion of growth. In this way he was enabled as a boy 
and as a young man to do more than the average 
amount of work without any personal aid whatever, 
and he now enjoys an active legal practice, not neg- 



58 GROWTH AND DEFORMITY. 

lecting vacation sports and pastimes ashore and 
afloat, although his attenuated lower limbs are in 
marked contras-t with an heroic torso and upper 
limbs. That he is not limited to locomotion in a 
wheel-chair is owing to the fact that the failing mus- 
cles and joints received mechanical encouragement 
at the time of growth, an advantage which might well 
be accorded to every case of this affection. 

Recognition of Mechanical Surgery. — It is evident 
that an instrument applied for the relief of disability 
following paralysis supplies a defect in the anatomy. 
To that extent it is a prosthetic apparatus. It need 
not, however, on that account be omitted from the 
armamentarium of the surgeon. The application of 
braces of all kinds is passing into professional hands 
from those of the instrument maker. In the dark 
ages, when surgical work was in the province of the 
barber, the medical men of the day probably waived 
professional convention when they ventured to take 
up the lancet and bistoury. 

In 1862 Dr. Stephen Smith wrote: "It must be 
evident to every one that mechanical surgery is a 
branch, and a most desirable one, of surgical science 
and art. It is not simply a branch of mechanics to 
which any ingenious artisan can successfully turn his 
attention ; it requires also an accurate knowledge of 
anatomy, of physiology and of surgery. Rationally, 
the mechanical surgeon must be a thoroughly edu- 



MECHANICAL SURGERY. 59 

cated physician as well as an inventive genius. Med- 
ical men of real merit have recently entered this field 
of service and already the ripe fruits of skilled labor 
begin to appear."' The far-seeing wisdom of this ob- 
servation is attested by the fact that within six years 
after these words had been penned, The New York 
Hospital for the Ruptured and Crippled and The 
New York Orthopaedic Dispensary and Hospital had 
been established or incorporated. The work done by 
these institutions prepared the way for the present 
wide recognition by charitable, educational, and gov- 
ernmental interests of the value of this field of special 
study and effort. 

An Orthopaedic Laboratory. — The following state- 
ment of instruments and materials is considerably 
reduced and modified from a schedule presented by 
Dr. Schapps, when he described the equipment of a 
new orthopaedic dispensary. These appliances are 
necessary for the application and modification of 
braces made to order from soft steel by an instru- 
ment maker: Work-bench, vise, screwdrivers, rivet- 
ing hammer, files, flat and cutting pliers, monkey- 
wrenches, Stillson's wrench, hack-saw, cold chisel, 
punches, centre-punch, copper rivets No. 13, various 
lengths, burs, steel wire for rivets, rivet set, shoe 
knife, scissors, snips, oil stone, can of oil, machine 
screws, broaches, taps, hand vise, eyelets and set, 
leather punch, foot drill or lathe, twist drills, machine 



60 GROWTH AND DEFORMITY. 

for general sewing, truss leather, felt, buckles for web- 
bing and leather, cotton surgical webbing, pans for 
holding rivets, burs, screws, buckles, etc. 

Apparatus not only Prosthetic but also Preventive 
and Therapeutic. — A brace applied in a case of infan- 
tile paralysis has especial value for a growing patient 
because its effect is not only to improve the present 
gait but also to induce related structures, which would 
otherwise have remained dormant, to develop by exer- 
cise and the increasing demands of coordination, 
until they play an important part in the attainment 
of ability and grace. An adult would of course gain 
some advantage, but far from the full benefit which 
would have been his if all the machinery of locomo- 
tion had made its growth under the influence of 
timely reinforcement of the deficient part. 

These disabilities require early and very prolonged 
attention in practice. When the lameness of a child 
is recognized as the result of infantile paralysis and 
acknowledged to be incurable the limp is considered 
unfortunate, of course ; but if the condition does not 
include absolute disability, it as a rule receives little 
serious attention in the way of treatment. Presently, 
however, as the child grows, the misfortune becomes 
more conspicuous. The machinery of locomotion 
falters more and more under, increasing weight, and 
when contractions and deformities are aflded to 
atrophy and muscular insufficiency, acute attention 



MECHANICAL SURGERY. 61 

is aroused and braces are sought and operations are 
performed. A better plan is to assume that me- 
chanical assistance is required at the outset — and 
will be necessary throughout the time of growth, 
and afterward. It is true that treatment thus pro- 
longed and troublesome can only palliate and not 
cure. It implies also exacting attention to me- 
chanical details, frequent supervision, and many al- 
terations and adjustments of apparatus in response 
to the demands of growth and increasing ability. 
Improvement in walking is seen at once, but more 
important benefits will accrue later when it is found 
that continued use of the brace promotes symmetry 
of the affected limbs and flexibility of the joints, con- 
serves muscular power which would otherwise have 
been lost through disuse, develops extensive related 
groups of muscles in other parts of the body, and pre- 
serves or restores various allied functions and abili- 
ties which materially add to the efficiency and com- 
fort of the adult. When practicable, this end is 
certainly preferable to the result of systematic neg- 
lect, or a spasmodic resort to treatment whenever its 
repetition seems to be especially necessary. In this 
direction a change is noted in the views of physicians 
and of the public. 

Orthopaedic Surgery as a Specialty. — While the 
troubles seen in the wake of infantile paralysis may 
be greatly relieved, the nerve lesion persists, and from 



62 GROWTH AND DEFORMITY. 

the nature of the case there will almost certainly be 
a lasting residuum of disability. The result of treat- 
ment falls short of perfection, but the same may be 
said as a rule of the treatment of spinal deformity 
and joint disease, and in fact of nearly all of the af- 
fections included in orthopaedic practice. This has 
been advanced as one of the reasons among others 
for the existence of such a specialty as orthopaedic 
surgery. The limitations of achievement are so con- 
spicuous and so sure to bring discredit upon medical 
authority that it seems to have been agreed that the 
inevitable may well be transferred to a specialist, who 
collects what is known on a certain subject, so that 
when the end of treatment is reached it may be said 
that the patient has received all that the science of 
medicine in its present state allows. The orthopaedic 
surgeon may be the depository of exceptional knowl- 
edge, but his work includes not many opportunities 
to obtain brilliant results or to achieve operative suc- 
cess, which is so greatly and so justly admired in the 
public mind. He throws a deformed foot into a new 
attitude in which increasing activity and growth pro- 
mote and insure symmetry. He gives to a tubercu- 
lous joint a new environment favorable to natural 
repair and recovery with an unexpected restoration 
of locomotor ability. He provides a reenforcement 
for a paralyzed limb which meets the immediate ne- 
cessity of the case and secures future activity and 



MECHANICAL SURGERY. 63 

comfort. A studious application of the methods of 
precision on which lie relies cultivates his aptitude 
for mechanics and fosters his respect for whatever is 
physically demonstrable. If he adds to natural in- 
genuity an inherited or acquired preference for slow 
and sure, rather than rapid and indeterminate meth- 
ods, he is in a position to witness and reverently to 
assist constantly recurring natural miracles in repair 
and recovery, not forgetting the friendship of his 
little patients, their pretty bashful ness, ready confi- 
dence, irrepressible cheerfulness and graceful accept- 
ance of what is, alas, inevitable. The combination 
in their young lives of childish and heroic qualities 
suggests a fantasy in which birds and wild flowers 
act a tragedy and improve the precepts of stoic phi- 
losophy. 



CHAPTER III. 

TUBERCULOUS JOINT DISEASE. 

An Affection of Childhood. — Its Causes. — Tubercu- 
losis of the joints is especially a menace to childhood ; 
and yet in this period, when the vital processes are at 
their best and growth and development are active, it 
would seem that natural resistance to general diseases 
should be alert and give protection from dangers of 
this kind. In early youth the circulation is rapid and 
full. Children are not easily deprived of their share 
of respiratory activity. They are not given to intro- 
spection and melancholy which has been thought to 
favor the approach of general or constitutional dis- 
ease. Their habits are far from sedentary. Their 
minds are free from worry and their bodies from 
overwork and long hours without rest and recreation. 
By this process of exclusion, their danger may per- 
haps be referred to some mismanagement of alimen- 
tation. Some unfortunates are, from sad necessity, 
denied sufficient food. Others perhaps suffer because 
prudent economy finds easy expression in a scanty 
allowance to the younger members of the family, re- 
enforced by a common and not altogether unreason- 

64 



TUBERCULOUS JOINT DISEASE. 65 

able idea that it is bad for a child to cat too much. 
Overeating may of course induce acute disorders of 

brief duration, but, on the other hand, prudence of 
tins kind may easily lead to the more serious mistake 
of opening the door for chronic affections by with- 
holding sufficient nourishment. Certain young pa- 
rents who have no reason for economy seem to have 
an idea that the precious object entrusted to their 
possession has delicate and sublimated qualities 
which, for a time at least, exempt it from the common 
necessity of an abundance of good food. Cases are 
very rare in which trauma can be proved to have 
been the cause of joint disease, although many " pre- 
vious histories" include a story o\ some injury, from 
a fall or otherwise, which preceded or accompanied 
the first symptoms and which is supposed to have 
caused the trouble. 

Operative and Mechanical Treatment. — While tuber- 
culosis in the tissue of a vital organ generally leads 
to the most untoward result, the .same affection de- 
veloped in a joint is seldom fatal. With the favor- 
able conditions accompanying the youth and growth 
of the patient recovery may be considered assured in 
advance. A method may be almost within our reach 
of arresting or favorably modifying this morbid proc- 
ess, wherever it may have gained a lodgment, and of 
thus prolonging life and lessening the sum of deform- 
ity and disability. Until this promise shall have 



66 GROWTH AND DEFORMITY. 

been fulfilled, however, it is useless to undertake 
positive treatment of tuberculous joints. In these 
days of brilliant and painless operations, and -wonder- 
ful discoveries in physics, it is not easy to wait for 
natural repair and recovery. The most interesting 
thing in surgery is the arrest of pain and the transi- 
tion from peril to safety which often follow a bold 
operation. The confident surgeon is like a military 
captain who by a well-timed advance changes defeat 
into victory, returning with the priceless trophy of 
life and health. But this achievement has not yet 
been seen in the surgery of tuberculous joints. A 
malignant growth may be successfully excised, but 
not the involved structures of such a joint. The 
earlier deposits have been traced, before and after in- 
fection, and withdrawn by Macnamara, Sherman and 
Bartow, and by other operators, but this procedure is 
not as yet established. The initial focus, in one or 
the other of the bones composing the joint, is pres- 
ently followed by others, superficial or remote from 
the articular surface, some of them coalescing in 
depots of broken-down tissue. This ambuscade 
leads to postponement of action until the joint is 
well occupied by the disease. At such a time con- 
servatism may seem to indicate thorough excision, 
but with the risk of sacrificing useful parts while 
overlooking remote points of diseased action. Among 
so many conditions implying doubt and undermining 



TUBERCULOUS JOINT DISH AS 11. 67 

confidence, mechanical surgery happily enc6\irages 
a reliance on wisely planned expectation, which 
brings relief from pain and gives full assurance of 
timely intervention by natural reparative proces 

The conservatism which brought honor to the 
name of William Fergusson substituted exsection for 
amputation, but the surgery of to-day conserves not 
only the limb but every possible structure. All the 
joints, and functions are to be retained rather than 
surrendered, especially in the case of a growing child. 
The fragments are to be kept and cherished because 
they will share in the development of the whole 
growing and learning body, a development stimu- 
lated by Nature's ever-present effort to supply what 
is deficient. This consideration is less important in 
the treatment of adults, who may well desire speedy 
recovery. But at the time of life when tuberculosis 
usually attacks the joints, prolonged treatment gives 
opportunity to direct the natural growth until the 
"alchemy of patience" reveals ultimate symmetry 
and ability. At this time internal resistance to dis- 
ease and natural efforts to repair the effects of dis- 
ease may be expected to promote the development of 
tissue, structure, and function. 

Intelligent Expectation. — Observation and experi- 
ence have matured the opinion that joint disease 
cannot be cured in the ordinary sense of the word. 
While it cannot be cut short, it is equally certain that 



68 GROWTH AND DEFORMITY. 

it will recover, albeit with some disability, and the 
physician who takes that ground at the beginning of 
such a case, in an adult or in a child, or as regards 
any part of the skeleton, will see his opinion proved 
by the event. He will save his patient from severe 
pain inflicted in vain efforts to retain or restore 
mobility. He will probably shorten the duration of 
the disease and certainly lessen the degree of ultimate 
ankylosis by intelligent efforts to subdue inflamma- 
tion. To the method of treatment thus outlined has 
been applied the term expectation, a word which is not 
strictly correct, because what is called expectation in 
these cases is characterized by radical changes in en- 
vironment, not the least of which is the substitution 
of rest for activity. The word rest does not mean 
very much if it implies merely cessation of work or 
the avoidance of fatigue, but it means a great deal 
when applied to a regulation in which an organ is ab- 
solutely restrained from its customary function. A 
prescription of this kind is common in medicine and 
surgery, but probably no more striking example will 
be found than that in which a joint is not only pre- 
vented from motion but is also released from the 
duty of carrying the weight of the body. 

The Prevention of Ankylosis. — At the first view it 
seems unreasonable to deprive a joint of motion in a 
crisis in which its mobility is threatened by disease. 
It has been found difficult to give to ankylosis its 



TUBERCULOUS JOINT DISEASE. 69 

proper value in the terms of this therapeutical prob- 
lem. From a review of the morbid anatomy of this 

affection, it is evident that when inflammatory action 
has swept through a joint the results resemble some- 
what those found in a house tested by a conflagration. 
The bones arc charred, so to speak, the articular 
surfaces are distorted, the ligaments arc fused and 
warped, and the synovial membranes are rendered use- 
less. Normal motion thereafter is out of the question. 
But it is also evident that the destructive process 
should be stopped as soon as possible. Thus far the 
surest method of subduing inflammation is an arrest 
of function. It is indeed the only effective resort. 
Fortunately it is applicable to a certain extent in 
every case of joint disease, and the point of practical 
and urgent importance is to recognize the necessity 
of it at the earliest possible moment. 

Fixation of an inflamed joint will lessen ultimate 
ankylosis by moderating the inflammation and abat- 
ing the quantity and density of its obstructive prod- 
ucts. It is credibly stated that fixation of a healthy 
joint for even an indefinite time is powerless to pro- 
duce ankylosis. It will interfere with normal motion 
of the joint, but the impairment of mobility produced 
in this way will be overcome in the course of time by 
effort on the part of the subject. This disability is 
very different from ankylosis following inflammatory 
disease, which is, with rare exceptions, permanent. 



70 GROWTH AND DEFORMITY. 

Let fixation, therefore, be applied as early as possi- 
ble, and with uncompromising persistence, with the 
knowledge that, so far as the joint is healthy, the ap- 
plication is harmless, and with the assurance that, so 
far as the part is diseased, fixation will, by checking 
inflammation in the joint, increase its ultimate mo- 
bility. It is noteworthy that, while the local environ- 
ment of a joint in the lower extremities is controlled 
by mechanical arrest of its functions, the same device 
modifies the general environment of the patient by 
substituting for the sick-room a^ life of activity out of 
doors. 

An Early Diagnosis is especially valuable in joint 
diseases of the lower extremity because on the date 
of the diagnosis depends, more than in many med- 
ical and surgical emergencies, the character of the 
prognosis. Treatment prescribed before the foci of 
morbid action have begun a destructive career under 
the incitement of habitual traumatism should, by 
averting violence, induce resolution with retention of 
motion and exclusion of deformity. That affections 
corresponding to hip disease and white swelling of 
the knee are almost entirely absent from the upper 
extremity indicates that tuberculous deposits are 
harmless in bones that are exempt from habitual vio- 
lence. It is no time for timorous hesitation or dread 
of making a mistaken diagnosis. Dr. Fayette Tay- 
lor would say that the house is on fire or it is not on 



TUBERCULOUS JOINT DISEASE. 71 

fire. Protective treatment, which is the first and 
chief requirement of such cases, is no real hardship 
for a few months in childhood or adolescence, it inter- 
feres in no serious way with a child's happiness, and 
may secure ability and symmetry for the rest of his 
life. To omit or postpone such a precaution may 
open a door to permanent disability and deformity. 

Chronic Synovitis. — When synovitis occurs in the 
course of tuberculous disease of a joint it is second 
not only in time but also in importance. Occurring 
thus, it requires no special attention. No reasons 
have been found in the clinical history or in the mor- 
bid anatomy of diseases of the joints, for the fear that 
synovitis may " run into " osteitis. The two affec- 
tions resemble each other in being of long duration 
and presenting a disposition intractable to any form 
of positive or active treatment. Non-rheumatic in- 
flammation of the synovial membrane may interfere 
with the action of a joint through excessive effusion, 
but the ligaments retain their properties and the 
neuro-muscular element of inflammation of the bones 
forming a joint is absent. When simple or pri- 
mary synovitis finally disappears it rarely leaves dis- 
ability or deformity. 

Whether the joint involved in tuberculosis is large 
and difficult to treat or small and easily controlled, a 
long time will almost surely be required for the res- 
toration of the part to health. Although the princi- 



72 GROWTH AND DEFORMITY. 

pies of treatment are few and simple and easily car- 
ried out, their application does not often meet a quick 
response. The beginning of the process of repair is 
apparently postponed until the occurrence of some 
general reaction, the nature of which is not clear. 

It is well, therefore, to undertake the treatment of 
such cases with the knowledge that recovery will be 
a tedious process. Excepting in those cases in which 
a very early diagnosis is made, the duration of treat- 
ment will probably cover several years. As an offset 
to this inconvenience, good functional ability, albeit 
with some lameness, may be confidently predicted. 
This outcome is assured, in an absolutely favorable 
environment, by the presence of youth and by the 
assistance derived from the vital activity which ac- 
companies growth. A splint is an unwelcome bur- 
den and an annoyance, but when applied to an adult 
it seldom entirely precludes the pursuit of ordinary 
business. Still less does it interfere with the educa- 
tion and amusements of a child, whose buoyant in- 
difference to personal inconvenience softens the hard- 
ship of mechanical restraint. Surely much can be 
done during the plastic years of juvenile growth to 
avert ultimate deformity and disability. 



CHAPTER IV. 

WHITE SWELLING OF THE KNEE. 

That an intimate knowledge of disease lies at the 
foundation of practice is not held by the faculty alone. 
Wherever there is sickness a physician who recog- 
nizes a disease, traces its origin and foretells its 
course is at once credited with ability to cure it. 
Pathology rightly holds the seat of honor in the tem- 
ple of /Esculapius. But how changeful is pathology ! 
How fickle a divinity! Mr. Adams (1854) wrote 
that the life of a pathological doctrine was about 
thirty years. We learn, but with the prospect of hav- 
ing to unlearn, and the all-wise, unwise public senses 
this and when in trouble goes doubtfully away " trem- 
bling, hoping, lingering, flying," to fanes where the 
divinities are not only fickle but meretricious. In 
the consideration of white swelling of the knee, how- 
ever, we recognize a pathological feature which has 
all the stability of exact science. Inflammation here 
is prolonged by the continued use of the affected 
joint, which goes from bad to worse so long as the 

patient stands and walks. 

7? 



74 GROWTH AND DEFORMITY. 

TREATMENT. 

Diagnosis should therefore be followed by release 
of the limb from duty. Night brings the recumbent 
position, and day should see the application of an 
ischiatic crutch, or some other device which secures 
protection of the joint from the weight of the body 
and provides for walking while only one foot reaches 
the ground. This was formerly thought to be im- 
possible. " Mais le corps humain peut-il conserver 
pendant des mots entiers F attitude vertical, touchant 
le sol par un pied settlement ? Evidemment non ; cest 
au-desstis de ses forces. L'avenir nous reserve sans 
doute de grandes surprises, et ce qui est impossible 
aujourd'hui deviendra peut-etre Jacile demain? This 
disposition of the limb, by improving its environ- 
ment, will hasten the natural reaction toward re- 
covery. 

Fixation. — The evils of weight bearing being fore- 
stalled, it remains to bring about the suppression of 
motion. Arrest of function is indicated in all cases 
of inflammation. In ophthalmia light is excluded 
and vision is placed in abeyance. Adhesive bands 
limit expansion of the chest in acute pleurisy. As 
respiratory activity contributes to the incurability of 
phthisis pulmonalis, occlusion of a bronchus might 
be followed by limitation of the area of serous sur- 
faces, by evacuation of the products of inflammation, 



WHITE SWELLING OF THE KNEE. 75 

and finally by cicatrization, processes which often 
take place in tuberculous joints. The pain of an ad- 
vanced stage of joint disease requires arrest of mo- 
tion, or fixation. It was the opinion of Mr. Brodie 
that the efficacy of "Scott's dressing," a famous 
remedy for white swelling of the knee, depended on 
layers of adhesive plaster applied in such numbers as 
to limit the motion of the knee, an effect which 
might have been produced by the oxide of zinc of 
Mr. Brodie's day but not by the flexible tropical 
gums which were proposed in the manufacture of 
plaster by Mr. Eyre in 1848 and perfected by Dr. 
Martin in 1877. 

The Fear of Ankylosis, Fa iifcy lop /iodic of the French 
disputants, still confuses the treatment of this affec- 
tion, as well as of other forms of joint disease. A 
physician naturally hesitates before deciding that a 
child, apparently health)', has so serious an affection 
as white swelling of the knee, and if he fears that 
resting the joint will cause ankylosis he fails to apply 
the most efficient remedy for inflammation and the 
surest preventive of ankylosis. Recognizing the fact 
that impairment of motion is not only a sign of dis- 
ease, but also an effort of nature to allay inflamma- 
tory action, let him promptly aid this effort by artifi- 
cially promoting fixation. Safety lies in preparing 
for impending ankylosis and in seeking to lessen its 
degree by all the means at hand. 



76 GROWTH AND DEFORMITY. 

Pressure and Counter-pressure. — To give absolute 
fixation to the hinge joint at the knee the simplest 
form of retentive apparatus is quite sufficient. It 




Fig. 43. — Points of Pressure and Counter-pressure for Fixation of Knee 

Joint. 

should make pressure at the points indicated by C 
and D and counter-pressure at A and B in Fig. 43. 
A splint having this action is outlined in Fig. 44, 
and is seen applied to a limb in Fig. 45. A similar 
splint worn by an adult weighed one pound and three 
ounces. The firm application of such a splint is at- 
tended by what appears to be an increase in the size 



1 1 

LUi 



\j 



|A CO B f 

Fig. 44. — Outline of Brace for Fixation of Knee Joint (1886) . 

of the joint, caused by repression of the soft parts 
above and below the swollen knee. There is also an 
apparent constriction of the limb, which is not real, 



WHITE SWELLING OF THE KNEE. 77 

because the omission to make pressure from behind 
forward at this level makes constriction and inter- 
ference with the circulation impossible. Such a 
splint also provides for the reduction of flexion. 
Conforming at first with the shape of the flexed 
limb, the instrument may be kept tightly buckled, 
and, being straightened from time to time, it will 
slowly, and with certainty in ordinary cases, draw the 
knee first into extension and then into hyperexten- 




FlG. 45. — lirace Applied for White Swelling of Right Knee. Boy. eight 
years old, 10 of hyperextension following 30 of flexion. 

sion. This painless process is made easy by the 
cheerful interest and assistance of the patient. It 
illustrates the mobility of the immobility, so to speak, 
which marks the early stage of all joint disease. In 
a painful stage a weight and pulley may be conven- 
iently used to begin the reduction of extreme flexion, 
but a splint with its advantage of long leverage above 
and below dominates the joint so powerfully that sue 
cess is certain if flexion has not become too resistant 
throueh delay. 



yS GROWTH AND DEFORMITY. 

Details of the Fixative Splint. — A plain bar of iron 
or soft steel is prepared for the posterior surface of 
the limb. To this are fastened four transverse pieces, 
curved to half encircle the limb. They are riveted, 
the middle ones to the posterior and the others to 
the anterior side of the upright bar. The upper and 
lower are padded, the others are left uncovered, as 
they do not touch the skin and have the simple duty 
of carrying buckles to receive pieces of webbing on 
which sliding pads mollify pressure from before 
backward, which is the key to the apparatus. With 
soft metal and simple tools, a physician remote from 
skilful workmen may give to his patient relief and 
the assurance of a straight limb. The same results 
are attainable by the use of the plaster-of- Paris dress- 
ing, which observes the same pressure points. The 
plaster splint will have to be reapplied occasionally 
as the knee straightens or else partly divided trans- 
versely, as was ingeniously proposed by Dr. V. P. 
Gibney, and straightened by the insertion of wedges 
of increasing size. 

Experience has taught that the splint is liable to 
be displaced by gravitation, which may be opposed 
by lacing the shoe in such a manner as to form from 
its upper part a cup, or socket, which receives the 
lower end of the brace and keeps it up. A rotary 
displacement is also sometimes troublesome. Reme- 
dies for this may be found in watchfulness at home, 



WHITE SWELLING OF THE KNEE. 



79 




IG. 46. — Device for Keeping 
Fixative Brace in Position 
(1901). 



in experimental changes in the length and shape of 
the pieces composing the splint, or in the addition of 
buckles and straps to the upper and lower transverse 
pieces. In a certain case the apparatus persistently 
sought the inner side of the 
limb where it aggravated 
a preexisting knock-knee. 
A piece of steel was there- 
fore fastened, as seen in 
Fig. 46, to the heel of the 
shoe at a suitable angle, 
which was ascertained by 
experiment, and made to 
coalesce with the upright by a sliding ring keeper 
(seen in Fig. 45). Thus controlled the apparatus 
kept its place behind and to the outer side, where it 
opposed both knock-knee and flexion. 

Knock-knee and Bow Legs. — A similar application 
should be absolutely effective in the correction of 
rachitic deformities of the lower limbs, advantage 
being taken of the natural growth, the increment of 
which should be enlisted in behalf of the patient in- 
stead of being allowed to add to the trouble, in 
further illustration of the line: "Just as the twig is 
bent the tree's inclined." It is difficult to see how a 
crooked limb can be treated with much success while 
the patient is on his feet, since a large part of the 
transverse pressure exerted by the brace must be ab- 



8o GROWTH AND DEFORMITY. 

sorbed in sustaining the weight of a child who is run- 
ning about all day. If, however, the foot is kept 
from the ground by suitable apparatus, one foot 
being treated at a time, or if the patient is recumbent 
while both of the limbs are under treatment, the chief 
mechanical obstruction is removed and the way is 
cleared for the positive action of a simple but power- 
ful lever on long bones in a more or less plastic and 
tractable state. Success should certainly follow the 
application of a fixative brace constructed of soft 
metal, or the use of any other suitable method or 
material. To recapitulate the mechanical points: 
the chief direct cause of the deformity, the impend- 
ing weight of the body, being removed, the plastic 
condition of the bones (which is the indirect cause) 
is converted and inclines the deformity to yield to 
treatment. The instrument should be kept on the 
side of the concavity of the curve, where counter- 
pressure is made at distant points by the padded 
ends of the brace, while pressure is made at the point 
of greatest divergence by webbing and buckles, the 
force thus applied being gradually and painlessly in- 
creased and the brace being straightened from time 
to time as the limb straightens. When the deformity 
has been neglected and has become confirmed by the 
hardening of the bones, an operation will be necessary 
before beginning mechanical treatment. Extremely 
good results follow the operative correction of these 



WHITE SWELLING OF THE KNEE. 81 

deformities by rapid osteoclasis applied at the upper 
part of the tibia, as signally demonstrated by Dr. 

Blanchard. 

DIAGNOSIS. 

An early diagnosis of white swelling of the knee is 
of great importance. In the following case an early 
diagnosis was followed by a perfect recovery. 

Case V. — Incipient White Swelling oj the Knee. 
— A girl seven years old, and apparently in perfect 
health, had been limping occasionally for several 
months. The range of passive motion was between 
20° and 1 70 of flexion. Attempts at full extension 
caused reflex resistance and twitching of the muscles 
of the thigh. There had been no subjective symp- 
toms. The signs included an increase of three- 
eighths of an inch at the knee, a decrease of three- 
eighths at the calf, and a decrease of five-eighths of 
an inch four inches above the patella. Treatment 
was begun in September, 1899. In the absence of 
pain fixation was postponed, and weight was re- 
moved from the limb by an ischiatic crutch with a 
high sole on the shoe of the well foot. At the end 
of a year there had been no further trouble, the swell- 
ing had disappeared, and normal motion had returned. 
In their new environment of quiescence the tubercu- 
lous centres, ignited somewhere in the cancellous 
structures above or below the line of the joint, had 

evidently been walled off and extinguished, as prob- 
6 



82 GROWTH AND DEFORMITY. 

ably happens when they menace the joints of pen- 
dent limbs, or other favored parts of the skeleton. 
In September, 1904, four years after treatment 
ceased, there was no sign of relapse. Motion was 
perfect and there remained only a slight difference in 
the measurements of the limbs. The benefit derived 
from the successful issue of this case was threefold : 
Dr. Romaine, the physician who made the diagnosis, 
escaped trouble at a time when it has entrapped 
many ; the specialist recorded a case which did not 
have the usual residuum of deformity; and the 
little patient was very fortunate, the happy results 
of an early and fearless diagnosis. 

An early recognition should, in truth, be often 
accorded to these cases. Unlike their situation in 
Pott's disease or in hip disease, the affected bones lie 
near the surface, and their motion (that of a hinge, 
the simplest in the anatomy) is so obvious that any- 
thing wrong may be seen at once. Among the first 
indications are an inconstant limp, slight increase at 
the knee, and decrease above and below the knee on 
comparison with the other limb, impairment of pas- 
sive motion near the limits of the normal range, reflex 
muscular action, an uneventful previous history, and 
the absence of subjective symptoms. When the dis- 
ease is established, its history, the characteristic white 
swelling, and a tendency to subluxation serve to dis- 
tinguish it from rheumatism. A few years ago am- 



WHITE , SWELLING OF THE KXEE. 83 

putation was a common resort in this affection, which 

in a painful stage leads to many lapses in diagnosis 

through simulation of malignant disease and acute 

osteitis. 

RESULTS OF TREATMENT. 

After white swelling, the patient must as a rule 
make himself contented with a knee which has no 
motion. With an ankylosed joint he is indeed un- 
fortunate if the knee is left in a condition of marked 
flexion. With this result he can of course sit very 
well, but when he rises the limb is shortened and de- 
formed by flexion; and a still worse condition i> de- 
veloped by the act of walking, in which the weight 
of the body, falling on a flexed and stiffened limb, 
takes it at a great disadvantage, so that locomotion 
is almost inevitably attended by pain and weakness. 

Flexion of the knee is therefore the chief evil to be 
combated in this affection. It attracts attention as 
an early sign and requires persistent restraint at all 
stages of treatment. It is liable to recur even after 
treatment has ceased and especially after an opera- 
tion has been performed on the bones, as has been 
forcibly pointed out by Dr. Townsend. 

On the other hand, it may be considered as a fortu- 
nate result if ankylosis has overtaken the joint when 
the knee is straight or hyperextended. Sitting will 
then be inconvenient, but when the patient stands 
and walks there is no deformity whatever and the 



84 GROWTH AND DEFORMITY. 

limb supports the body with confident firmness and 
without pain, although walking will be somewhat in- 
terfered with. 

In the complex act of walking the foot swings for- 
ward to receive the weight of the advancing body, 
and this requires that the limb be shortened by slight 
flexion of the knee. When this is prevented by a 
stiff joint the gait may be improved by raising the 
heel of one shoe and lowering that of the other one. 
This simple device, which is almost entirely neg- 
lected in providing against this disability, is especially 
applicable when the affected limb has been length- 
ened by epiphyseal hyperaemia in the acute stage of 
the affection. Some defect in the gait will be pres- 
ent, but not enough to prevent effective walking 
and prolonged effort in locomotion. 

As a normal knee may be hyperextended ten de- 
grees and sometimes fifteen degrees hyperextension 
is to be sought rather than avoided as a result. In 
this position the broad articular surfaces are mutually 
adapted to planes of contact and become a safeguard 
against a relapse to flexion. Not only the surfaces, 
but also the ligaments of the joint may thus be favor- 
ably disposed toward the maintenance of stability in 
weight-bearing and locomotion. Leaving out of con- 
sideration those rare cases in which motion is quite 
normal, or so wide as to include full extension and 
enough flexion to facilitate sitting, the best result after 



WHITE SWELLING OF THE KNEE. 85 

this affection is a knee ankylosed in extension or hy- 
perextension. Limited motion is of but little use ii 
it does not include complete extension. A common 
result is a diminution of the circumference of the 
limb, appearing worse than it really is from contrast 
with a limb which has been overworked and unduly 
developed. It has no effect on locomotor ability. 
Subluxation, although a remarkable deformity, is 
not of itself a seriously disabling incident. If the 
limb recovers fully straightened subluxation throws 
the axis of the lower bone somewhat behind that of 
the upper one, but not enough to compromise sup- 
port by a straight bony section from the ground up. 
When abscesses occur they have the appearance of 
being a grave complication, but like those of hip 
disease they evidently have no effect on the duration 
of the affection or the quality of its results. They 
may, therefore, be left to take their own course. 
The affected joint calls for protection and fixation 
while a good position is insured by the maintenance 
of hyperextension throughout the period of growth. 
The want of adequate attention at home can alone 
excuse recovery with ankylosis in a flexed position, 
as correction should lie well within the power of so 
simple a device as a lever. As in many other ortho- 
paedic emergencies, success depends very much on 
the cooperation of the patient, or, in the case of a 
young child, on that of the mother or of the nurse, 



86 GROWTH AND DEFORMITY. 

whom it is often not out of place to remind that the 
brace is to be worn, not only on the child's limb, but 
also in her head. 

The amount of flexion may be measured while the 
patient lies on his well side, by holding one arm of 
the goniometer parallel with the axis of the shaft of 
the femur, or with a line connecting the trochanter 
and the middle of the knee, and the other arm of the 
instrument parallel with the crest of the tibia, when 
the degree of flexion may be read on the scale. The 
instrument should occupy a plane parallel with the 
plane of the leg and flexed foot. 

Ankle Disease. — Dr. V. P. Gibney, referring to 
caries of the ankle in children, expresses a sound 
practical opinion as follows : " The expectant plan, 
fully carried out, assures us of more results that are 
perfect, and more limbs that are useful without the 
aid of support than does any other plan known to 
the profession." In the treatment of disease of this 
joint especial attention should be given to the main- 
tenance of protection from the weight of the body, 
fixation being sufficiently secured by the action of the 
muscles of the limb. A patient of Dr. Schapps, 
affected with disease of the ankle and tarsus, applied 
to his disabled limb " an old-fashioned peg-leg," which 
shifted his weight from the useless foot to the flexed 
knee. He thus promoted recovery secundztm artem 
while doing his duty as a fireman. 



CHAPTER V. 
TREATMENT OF HIP DISEASE. 

Basis of Mechanical Treatment. — Hip disease seems 
to be rated by the public as an incurable disease. It 
is true that when it is fairly established there is no 
hope of a return of the joint to a normal condition; 
but it is far from being a fatal disease. It may be 
confidently predicted in every stage that the time will 
come when nature will rally her forces and dictate 
the ascendency of repair over destruction. Would 
that it were possible to cut short the morbid process 
by an operation and thus secure symmetry and abil- 
ity! Unfortunately the hip patient cannot be cured 
as if he had a calculus, a diseased appendix, or an 
aneurismal tumor. And yet the management of hip 
disease is by no means a matter of perfunctory ex- 
pectation. Excellent service may be rendered, with 
abundant opportunity for the exhibition of surgical 
qualities. 

Obviously the first thing to do is to relieve the 
joint from supporting the weight of the body. It 
may be borne in mind that the ruthless character of 

the disease is the result of untoward mechanical en- 

87 



88 GROWTH AND DEFORMITY. 

vironment. Its counterpart is not found in the up- 
per extremity, where the foci of disease in the can- 
cellous tissue are resolved at an early day, by reason 
of the exemption of the arm from the labor and hard- 
ships attending locomotion. 

Something more than this, however, is required in 
the tedious course of the disease. There are periods 
in which the pain caused by motion leads the patient 
to steady the limb by adducting it against its fellow, 
and even by flexing it against the body where the 
hands may assist in fixation. In this emergency me- 
chanical treatment introduces what Mr. Thomas 
termed a fractional degree of fixation, which allays 
pain, and when the pain has ceased enables the pa- 
tient to dispose the limb in the position of least 
deformity. Mechanical interference should promote 
recovery, directly by inviting resolution, and indi- 
rectly by releasing the patient from confinement and 
invalidism and sending him out of doors. 

HISTORICAL NOTES. 

Accepted views of the pathology and treatment of 
hip disease have greatly changed in the last forty 
years. A distinct advance is seen in a better appre- 
ciation of what can be done to modify favorably the 
course and result of the disease, which of late years 
is said to be managed rather than cured. Provision 



HIP DISEASE, HISTORICAL NOTES. 89 

is made for promoting the "natural cure" and for 
securing- the minimum of ultimate disability. In cur- 
rent discussions the misapplied word extension has 
given place to traction. Surgeons were formerly 
troubled by spontaneous dislocation, which is now- 
forgotten. In a warm discussion, Dr. March, of Al- 
bany, declared that it "seldom or never took place," 
basing the statement on " personal examination of 
about forty pathological museums in this country and 
Europe," and Dr. George Hayward, of Boston, re- 
plied: " It would require more specimens than would 
fill forty, or forty thousand, pathological museums to 
convince me that this (related) case was not a spon- 
taneous dislocation of the femur." 

The Use of Adhesive Plaster for Traction. — The 
merits of this rather nice question were presently 
lost to view when the application of sticking plaster 
replaced the various painful and clumsy methods 
which had been necessary whenever it was desirable 
to treat a broken bone by laying hold of the limb be- 
low the seat of the fracture. Traction was thereafter 
applied in cases of hip disease, not to reduce spon- 
taneous dislocation, but to relieve pain and promote 
recovery. Prehension of the limb by adhesive plas- 
ter in the treatment of fractures had been advocated 
by Dr. S. D. Gross in 1830, but it was not adopted 
until attention had been recalled to the subject in 
1850 by Dr. Jpsiah Crosby, one of whose patients de- 



90 GRO WTH AND DEFORMITY. 

scribed his sensations by saying: "It feels as if my 
leg was in the mud and I was trying to pull it out." 
This was a homely but hearty recognition of the 
value of a device which has displaced the handker- 
chief knotted about the ankle, the buckskin gaiter 
and similar painful appliances which were parts of 
the old long fracture splint, and which were doubt- 
less used by Mr. Brodie (1834) and others when they 
experimented with the weight and pulley in hip dis- 
ease. A French apparatus described in 1865 made 
traction in the recumbent position by pressure against 
the calf of the flexed leg. 

Drs. Henry G. Davis and L. A. Sayre simultane- 
ously described the application of adhesive plaster 
for traction in hip disease in i860. The injurious 
effects of muscular action on the joint, and their pre- 
vention by traction, became at once the subjects of 
observation and discussion. Interest was excited to 
such a degree that in the following year the merits 
of the new treatment of hip disease were discussed at 
three successive meetings of the New York Acad- 
emy of Medicine by Drs. Batchelder, Bauer, Bron- 
son, Gurdon Buck, H. G. Davis, Finnell, Holcombe, 
Krackowizer, Miner, Parker, Post, Raphael, Sayre, 
Stevens, Watson, and Wood, and four years later 
in a series of sessions of the Surgical Society 
of Paris by MM. Blot, Boinet, Bouvier, Broca, 
Depaul, Dolbeau, Follin, Giraldes, Hervez de 



HIP DISEASE, HISTORICAL NOTES. 91 

Chegoin, Le Fort, Marjolin, Trelat, Velpeau, and 
Verneuil. 

In these discussions and in contemporaneous writ- 
ings the supposed effects of muscular contraction 
received unwonted attention. The action of the 
powerful muscles of the hip seemed to threaten the 
integrity of the cartilages and bones composing the 
joint and to find in traction a worthy opponent. 
From these clinical premises, and too hastily, the 
conclusion was drawn that traction was curative be- 
cause it saved the joint from being destroyed by the 
contracting muscles. The advocacy of this method 
by Drs. Davis, Say re, and Fayette Taylor opened a 
field of observation and experiment which has been 
under ingenious cultivation ever since. An incom- 
plete list of questions which have been answered in 
different ways includes the following: the question 
of separating the articular surfaces, of moderating 
articular pressure, of stretching the muscles until 
they were paralyzed, of keeping them stretched while 
motion was permitted in the joint, and the important 
but at first neglected question of fixation. 

The hip splint was called by Europeans the 
American splint. As first described in i860 it had two 
principal features: a perineal strap, or crutch-head, 
for receiving the weight of the body, and sticking 
plaster for making traction. The device by which 
the body is supported in the hip splint when the pa- 



92 GROWTH AND DEFORMITY. 

tient is erect cannot be said to have had its origin in 
America. But the other distinguishing feature of 
the splint, adhesive-plaster prehension, was an im- 
provement rightly credited to American surgery. 
Thus the apparatus combined an old and a new de- 
vice, the latter American, and, as the combination 
was made here, European writers courteously named 
the method and splint American. 

Many changes have been proposed in the appa- 
ratus. In the "short hip splint" the .upright ex- 
tended only to the middle of the leg, and the pa- 
tient's foot was allowed to rest on the ground. It 
was thought that when the instrument was keyed up 
the plaster would have sufficient strength and adhe- 
siveness to resist the weight of the body and prevent 
it from making pressure on the joint. When this 
was found to be a vain hope, the apparatus was made 
to reach the ground and the weight of the body was 
transferred from the plasters to the ischium, prac- 
tically producing a crutch applied under the leg 
instead of under the arm. Aside from this, no 
important change has been made. The splint has 
been modified experimentally for the enforcement 
of extension, abduction, motion without friction, 
relief from articular pressure, and counteraction of 
the circumarticular muscles. The attainment of 
these objects may or may not have been useful in 
certain stages. Experience has shown that certain 



TREAT ME XT OF HIP DISEASE. 93 

effects supposed to be produced were impossible, and 
others which might have been practicable were un- 
necessary. The value of the American method 
would perhaps have been more widely recognized 
even than it has been if too much had not been 
hoped from it. Traction simply stays the joint and 
relievo pain, and the perineal support effectively 
protects it from the traumatisms of standing and 
walking, while the patient runs about and follows 
the ordinary pursuits of his time of life for the 
months and years required to bring about recovery, 
with restoration of ability and symmetry, so far as 
may be. 

BASIS OF TREATMENT BY THE SPLINT. 

There are reasons for withholding assent from an 
opinion of the early advocates of this method, that 
traction owed its efficiency to its ability to overcome 
the muscles which were thought to be destroying the 
joint by their reflex contraction. This presupposed 
an inadmissible vicious circle, in which the destruc- 
tive process excited muscular action, while muscular 
action aggravated the destructive process. Accord- 
ing to one theory, the muscles should be stretched by 
the elastic power of India-rubber straps until they 
were paralyzed. This, however, was not likely to 
happen because opposition and exercise develop in- 



94 GROWTH AND DEFORMITY. 

stead of exhausting the power of muscular fibres, 
which would hardly surrender their supreme endow- 
ment of contractility to anything short of rupture 
or degeneration. If, on the other hand, the traction 
applied were inelastic and unyielding, the stretching 
which it could give to the muscles would soon have 
been arrested by the ligaments, and in any event it 
would have been insignificant in view of the elonga- 
tion to which they had been accustomed in the alter- 
nations of contraction and relaxation. According to 
another theory the muscles might be kept from in- 
creasing joint pressure by a splint making traction 
and permitting motion of the joint at the same time ; 
but insurmountable difficulty was found in trying to 
keep such a force in action through the variations 
and combinations of extension, flexion, abduction, 
and adduction. If, indeed, traction could have been 
applied directly to the bone without the intervention 
of the soft parts it possibly might have been in a posi- 
tion to counteract the muscles. It had to be applied, 
however, to the skin, which was but an elastic en- 
velope of a mass composed largely of relaxed muscu- 
lar and yielding connective tissue. These interest- 
ing speculations were prompted by what was believed 
to be a most important discovery. When traction 
was applied by a splint to a painful joint the appear- 
ance certainly was that of muscles subjected to coun- 
teraction, and when relief from pain immediately 



TREATMENT OE HIP DISEASE. 95 

followed, the inferences were natural that muscular 
action was a mischievous factor and that it was suc- 
cessfully overcome by traction. The enthusiasm 
excited by such signal relief, produced by means - 
simple, is reflected in the writings of those who first 
witnessed the seeming miracle. 

The facts of morbid anatomy indicate that the de- 
struction of the joint is not caused by muscular con- 
traction. If it were, the evidences of friction would 
be seen in the acetabulum as well as on the head of 
the femur. In a large proportion of the tabulated 
cases, however, the acetabulum is unaffected. In 
the earliest incipiency of the disease the lesion (as 
is shown in Figs. 47, 48, and 49) is in the cancellous 
tissue, which is remote from possible injury. In a 
later stage, when ulceration appears, it is not on areas 
exposed to friction but chiefly on the neck of the 
femur, as in Figs. 50 and 51, and when the disease is 
in full possession it proceeds from within outward, 
as in Figs. 52, 53, and 54. It is not uncommon in- 
deed to find specimens bearing evidences of direct 
injury, but as many patients are active on their feet 
without the protection afforded by apparatus, the 
destructive pressure is as likely to have come from 
weight as from muscular contraction. Fig. 55 shows 
a specimen after an operation in the third stage. In 
this case an unaffected area appears on the summit of 
the head, which is the part most likely to feel the in- 



96 GROWTH AND DEFORMITY. 

jurious effects supposed to be produced by muscu- 
lar action. In this concise review, evidence has not 
been found of the destructive agency of the muscles. 





Fig. 47. Fig. 48. 



Figs. 47, 48. — Specimen from Boy Four Years Old. Duration of disease, 
four months. Death from tubercular meningitis. (Fricke, 1833.) 




Fig. 49. Fig. 50. 

Fig. 49. — Exsection. Recovery. (Volkmann, 1879.) 

Fig. 50. — Exsection. Girl eleven years old. Duration, two years. (T. 
Holmes, 1869.) 



TREATMENT OF HIP DISEASE. 



97 



The diseased bones are highly vascular, and fragile 
to such a degree that an exploring needle has been 
used in diagnosis. They might well be expected to 




Fir,. 51. — Specimen from Boy Five Years Old. Duration, several months. 
Death from tubercular meningitis. (Banvell, 1SS1.) 





Fig. 52. 



Fig. 53. 



Figs. 5: 



53. — Boy, Eight Years Old. Duration, several years, 
from intercurrent disease. (Y. P. Gibney, 1S7S.) 



Death 



show the effects of severe pressure, since healthy 

vertebral tissue yields to the impact of an aortic 

aneurvsm. If the force projected in the manner sup- 
7 



98 GROWTH AND DEFORMITY. 

posed were such a menace as to require the exhibi- 
tion of traction carried to the not uncommon meas- 
ure of fifteen pounds, it should lead to perforation 




Fig. 54 



Fig. 54. — Exsection. (Volkmann, 1879.) 

Fig. 55. — Exsection. Recovery. Boy fourteen years old. (L. A. Sayre, 

1S76.) 

of the floor of the acetabulum and invasion of the 
pelvic cavity by the decapitated femur. 

Reasons for Applying Traction. — It is not necessary 
to go very far to find good and sufficient reason for 
this procedure. If traction secures fixation of a joint 
so intractable as the hip its application is amply jus- 
tified. To immobilize the hip has always been a 
difficult problem. Mr. Charles Bell said : " No in- 
strument has ever been effectual in keeping the thigh 



TRACTION IN HIP DISEASE. 99 

and trunk fixed.'' Desault held the opinion that trac- 
tion made by his long fracture apparatus immobilized 
all the joints from the hip to the tarsus. His splint 
consisted " in taking the points of extension above, 
on the tuberosity of the ischium and below on the 
malleoli; in securing the straps or rollers for making 
extension on' the two ends of a strong splint placed 
along the outer side of the limb, and converting, so 
to speak, the pelvis, the thigh, the leg, and the foot 
into one entire and solid piece." Lesauvage wrote 
that one of the objects of continued extension in hip 
disease was to prevent motion. Mr. Lis ton, dis- 
paraging the weigh t-and-pulley experiments of Mr. 
Brodie, said : " All this may amuse the patient's mind, 
perhaps, but I do not think any good can come from 
it further than preventing motion." M. Philipeaux 
writes that traction may be employed to secure im- 
mobility of the limb. Dr. Fayette Taylor referred 
to " the quiet fixation of the joint which the splint 
has been a convenient means of accomplishing." Di\ 
Louis Bauer said: " Whatever benefit I have derived 
from it (extension) is unquestionably due to its fixing 
the affected articulation." Mr. Thomas wrote that 
extension involves unavoidably " a fractional degree 
of fixation." Dr. Yale writes: "When the muscular 
spasm is urgent, fixation cannot be secured, save by 
the use of force as constantly acting as that which is 
to be overcome, and the agent best adapted to this 

LrfG. 



ioo GROWTH AND DEFORMITY. 

purpose is traction." Dr. Wyeth writes: "Exten- 
sion is made by means of the screw key, until there 
is freedom from pain and a comfortable fixation of 
the limb." Dr. Shaffer writes : "When traction ex- 
ists the patient has the advantage of that peculiar 
and perfect immobility which the extension of the 
long hip splint affords." 

Function of the Muscles.— The muscles have a two- 
fold function : they move the joint and they fix the 
joint. If their action is at a point'remote from the 
centre of gravity of the body, they are more effective 
in both motion and fixation because of the dispropor- 
tion between the part above and that below the point 
of motion. There was philosophy, as well as humor, 
in Dundreary's witticism : " Why does a dog waggle 
his tail? Because the tail can't waggle the dog." 
This action is not only motion, but also arrest of mo- 
tion, right and left. It follows that if the part below 
is more easily moved on account of its comparative 
lightness, it is also more easily fixed for the same rea- 
son. This makes joint disease less serious the nearer 
it is to the distal phalanges. Aside from the insta- 
bility of the ball and socket at the hip, if the whole 
limb were no heavier than the foot hip disease would 
not be more serious than ankle disease. Mr. Hilton 
related a case in which the patient, who had hip dis- 
ease and white swelling of the knee of the same limb, 
recovered rapidly from the former after amputation 



TRACTION IN HIP DISEASE. 101 

above the knee. His comment was: " In fact, I may 
say that the hip joint was cured by cutting off the 
leg." 

It may also be borne in mind that the hip is pecul- 
iarly disturbed by the movements of other joints. 
In the words of Charles Bell: "There is no rest to 
it ; every motion of the body may be said to be ac- 
companied with a movement of the head of the femur 
within its socket; even if the arm be raised, there is 
a change in the centre of gravity of the body, and 
the trunk must be poised anew upon the hip, as the 
centre of all our motions. It is remarkable how the 
slightest degree of movement in another part of 
the body is, as it were, necessarily accompanied with 
a motion of the surfaces of those bones which com- 
pose the hip-joint. If ever you should see a patient 
suffering with acute inflammation of the hip, you 
will see the proof of this ; for every motion of the 
body gives extreme pain, and proves an additional 
source of excitement and inflammation. It is this 
consideration which leads us to understand the diffi- 
culty of curing the disease." 

A retentive splint, so useful in the surgery of frac- 
tures, is at a disadvantage when applied to the hip 
on account of the short lever above the seat of mo- 
tion, extending only from the acetabulum to the crest 
of the ilium. If it were equal to that below, or if the 
pelvis and vertebra? were replaced by a long bone, 



102 GROWTH AND DEFORMITY. 

retention would be as easy as at the knee. In like 
manner the treatment of Colles' fracture of the wrist 
may be simplified in the imagination by fusing into 
one piece the parts of the skeleton below the frac- 
ture. A toy cup and ball furnishes an illustration. 
The long handle of the cup gives more than enough 
leverage, but a retentive contrivance would fail un- 
less additional leverage were given to the ball by driv- 
ing a stick into it to serve as a handle or lever. 

Correlation of Traction and Fixation. — In the pres- 
ence of the mechanical difficulties which hamper 
fixation of the hip-joint by retentive means, hopeful 
resort may be had to traction. Simple Retention, 
however, has been applied to the hip, and with con- 
siderable success, notwithstanding its disadvantage 
of short leverage. This is true especially in the use 
of the splint invented by Mr. Thomas. Other ex- 
amples are also found. Dr. Coates, referring to Dr. 
Physick's hollow carved wooden splint, which ex- 
tended from the malleoli to the middle of the thorax 
and included one-half of the trunk, wrote : " The pa- 
tient frequently stated that he had obtained in the 
night following its application sounder sleep than for 
many weeks, or even months, previously." M. Bon- 
net wrote : " I have seen the pain and inflammation 
disappear as soon as the limb was brought into posi- 
tion and held immovable " by le grand ap par eil, which 
included two-thirds of the circumference of the lower 



TRACTION IN HIP DISEASE. 103 

limbs and trunk. " From the moment of application 
the pains diminished." M. Philipeaux, relating his 
experience with the same apparatus wrote: 'The 
next morning I learned that the patient, who had 
moaned incessantly the night preceding the applica- 
tion, had slept calmly for four hours." Mr. Noble 
Smith, referring to Mr. Chance's splint, which in- 
cluded the thigh and a large part of the trunk, speaks 
of "the almost immediate relief from pain which the 
patient experiences when the splint is applied.' On 
the other hand a number of instances may be cited 
of the remarkable relief from pain produced by Trac- 
tion. It was observed by M. Blandin that, on the 
application of extension and traction, the acute pains 
of hip disease "disappeared as if by enchantment." 
Mr. Brodie described a weight and pulley applied "in 
line with the thigh bone" and added: " It is aston- 
ishing what comfort I have known this to give 
the patient." Gustav Ross wrote that when the 
weight and pulley were used in the hip disease of 
children " the pain lessens astonishingly." Dr. Wat- 
son, of the New York Hospital, relating a case of 
acute hip disease when the new method of treatment 
was discussed by the Academy of Medicine, said : " I 
had hardly put on the counter-extension before the 
girl was entirely free from pain. It operated beauti- 
fully and instantly." Dr. E. S. Cooper, of California, 
describing an ingenious device for traction, wrote: 



104 



GROWTH AND DEFORMITY. 



" Often have patients slept better the first night after 
its application than they had for many months previ- 
ously." When pain is thus seen to be controlled 
equally by tractive and retentive apparatus, the cor- 
relation of traction and retention is evident. 

Character of the Pain. — It has been thought that 
relief follows too promptly to be rightly considered 
as the ^result of purely mechanical interference. It 
may be said, however, that the pain of hip disease is 
composed largely of apprehension and fatigue, both 
mental and muscular, attending prolonged voluntary 
and reflex efforts to prevent motion, with sharp ac- 
cessions when motion is made inadvertently, or as 
the patient starts when falling to sleep. Such pain 
is instantly relieved and prevented by whatever pro- 



-\£> 



A B ~C~Q 



6 

Fig. 56. — Fixation by Weight and Pulley. 

tects the joint from disturbance. In some cases 
severe pain, not controlled mechanically, probably 
indicates a collection of matter in the bony cells. 
That traction secures fixation is capable of demon- 



TRACTION IX I IIP DISEASE. 



105 




stration. Take two iron rods, A B and B C in Fig. 
56, resembling two links of a surveyor's chain. If 
the free end of one is attached to a wall while trac- 
tion is applied by a weight and pulley to the free end 
of the other, mobility is seen to be 
absent from their joint so long as 
adequate traction is maintained. 
This explains the action of " Buck's 
extension" in fractures. To say 
that traction stretches the muscles 
until they act directly as retentive 
splints overlooks the lengthening 
which belongs to them in custom- 
ary relaxation. The fixation thus 
produced in the two links of chain 
by a weight and pulley may readily 
be disturbed by a competent force, 
but if a tractive splint be substituted for a weight 
and pulley the result is remarkably firm and inde- 
structible. 

When the splint is applied to a patient fixation is 
promoted also by the action of what is known in 
mechanics as a brake. The perineal strap retards 
motion by making friction on the region to which it 
is applied. In Fig. 57 the circle represents the pel- 
vis, the point A the joint, A B the femur coalescing 
with the upright of the splint, and C D the strap, prac- 
tically of one piece with A B applied to the ischium. 



B 

Fig. 57.— A Mechani- 
cal Brake (18S3). 



106 GROWTH AND DEFORMITY. 

When traction is enforced by the rack and pinion, 
motion at A is retarded by friction. The splint also 
acts, although at a disadvantage, as a retentive appa- 
ratus, being assisted in this function by restraints ap- 
plied above the knee, which limit motion at the knee 
and promote coalition of the thigh and the upright. 
Paradox in the Treatment of Joint Disease and Frac- 
ture. — The idea that hip disease and fracture of the 
femur require similar treatment is not very new in 
medical literature. In 1779 David de* Rouen wrote 
that " notable cures of disease of the joints are to be 
effected by allowing the parts to remain undisturbed 
in splints, as in the treatment of fractures." M. Bon- 
net presented le grand appareil for hip disease in 
1845, after having described it in 1839 as a fracture 
apparatus, and the complicated method of M. Martin 
was prescribed in 1850 for fracture and in 1865 for 
coxalgia. Mr. Ford (18 10) compared hip disease with- 
out sinuses to a simple fracture, and Mr. Brodie made 
this comment: "If the cartilage be extensively de- 
stroyed without suppuration, the case may be com- 
pared to one of simple fracture ; and if there be sup- 
puration, it may be compared to one of compound 
fracture, a statement which led Dr. March to ask 
(1853): " If there be some analogy between the con- 
dition of the hip-joint in morbus coxarius and frac- 
ture of the neck of the bone, why should there not 
be some similarity in the mode of treatment?" As 



THE HIP SPLINT. 107 

if to enforce his view, lie invented, and described 
with a cut, a hip splint which resembled in its action 
the long fracture apparatus of Desault. There is an 
obvious incongruity in the proposition that the same 
treatment is applicable in an emergency in which ar- 
rest of motion is essential to recovery, and in an af- 
fection in which mobility is earnestly desired. An 
escape from this predicament lies in accepting the 
proposition that when a joint is inflamed ultimate 
mobility is to be sought by arresting motion and thus 
minimizing the products of inflammation. 

DETAILS OF TREATMENT BY THE SPLINT. 

The upright of the hipspint is usually made round 
in shape, as is shown in Figs. 58 and 61. The splint 
shown in Figs. 59 and 60 is flat, the metal being dis- 
posed in the direction of the strain. The lateral 




Fig. 58. — Round Hip Splint and Knee-piece (1SS0). 

strain falls with exceptional severity on the splint 
when two perineal straps are in use. But with a sin- 
gle strap, the weight falls almost vertically on the up- 
right, and a lateral distribution of the metal is unnec- 



io8 



GROWTH AND DEFORMITY.. 



essary. The splint may then be made from steel 
tubing as seen in Fig. 61, a number of bars of vari- 





u 



Fig. 59. 



Fig. 60. 



Fig. 61. 



Fig. 59.— Flat Hip Splint (1885). Fig. 60.— Flat Hip Splint Complete. 
Fig. 61.— Steel Tube Splint (1903). 

ous lengths being made for each barrel to meet the 
requirements of longer and shorter limbs. Some 
advantage is gained by giving the length to the bar 



THE HIP SPLINT. 109 

rather than to the barrel, an arrangement seen in 
Figs. 59, 60, and 61, which brings the key and the 
bulk and weight of the apparatus near the body, 
where they are more conveniently managed than 
when near the foot. The splint shown in Fig. 60 
weighs from two pounds to four pounds and eight 
ounces. The different parts of the splint and their 
uses are well known. The knee piece is of soft 
metal for bending to fit the limb and is adjustable 
vertically on the upright. It limits motion at the 
knee and, pari passu, at the hip. The pelvic band is 
a nearly semicircular bar of inflexible steel, adjust- 
able at the selected angle, usually a right angle, 
where it is immovably fixed by a bolt and nut. If 
extreme flexion is present this band should take a 
marked angle. The screw holes at its ends are " up- 
set " on the inner side before the band is covered 
with Vulcanized rubber, or wound with adhesive plas- 
ter to prevent rust, and Canton flannel or silk cut 
bias in strips. The perineal strap is of webbing, 
doubled for a heavy patient, softened with some 
woollen stuff, and covered with Canton flannel. It 
may be washed and has a loop for buttoning 
on the ends of the pelvic band over the screw 
heads. 

Key to the Application. — The determination of the 
length of the strap is the key to the successful use of 
the splint. If the perineal strap is too long it allows 



no 



GROWTH AND DEFORMITY. 



the pelvic band, when weight is thrown on the splint, 
to rise to such a level as to abrade the skin covering 
the anterior superior spinous process of the ilium, 
the level of which is indicated by the transverse line 
drawn in Fig. 63. If, on the other hand, the perineal 
strap is too short, it holds the band down where it 
makes intolerable pressure on the pubic crest. It 
would seem that a transverse depression had been 

provided between these two 
levels, in which pressure is 
harmlessly received by the 
abdominal wall. It is well 
to ascertain by experiment 
the right length of the strap, 
and then to attach it by 
loops, instead of by buckles 
which permit careless ad- 
justment. If the strap is a 
simple ischiatic support it 
may be left on the band 
and the apparatus may be 
pulled on over the foot. A band which is held at a 
low level on the pelvis by a short strap implies a 
short, light, and convenient upright, and the band 
can be smaller than it would have to be if worn with 
a long strap at the level of the iliac crest or ribs. 
Another advantage will appear in the fact that a 
band thus kept in its proper place will be below a 




Fig. 62. — Wooden High Sole. 



THE HIP SPLINT. 



in 



spinal brace or plaster jacket if concurrent disease of 
the spine requires treatment. 




Fig. 63. Fig. 64. 

Figs. 63, 64. — Splint Applied for Protection, Weight of Body Thrown Al- 
ternately on the Splint and on the Well Foot, Carrying Strap Relaxed 
and Tense. Pelvic band kept below level of iliac spine by short seat 
strap. 

To Give Protection the upright should be of such 
a length as to keep the heel, but not necessarily 



112 



GROWTH AND DEFORMITY. 




the toe, clear of the ground. Concussion passes 
from the heel directly to the diseased joint, but from 
the toe indirectly, and softened by the elastic action 
of the muscles moving the tendo Achillis. A carry- 
ing strap (seen in Figs. 
63 and 64) is made from 
a piece of wide webbing 
which passes under the 
head of the upright and 
crosses the opposite 
shoulder .to buckle in 
front at the convenience 
of the patient. As the 
splint extends quite a 
distance below the foot, 
the well foot will have a 
high sole, a convenient 
form of which is seen 
in Fig. 62. Thus pro- 
tected, the affected limb 
is a pendent member, 
the perineal strap being 
practically a crutchhead. 
Dr. Fayette Taylor 
wrote that " the patient 

Fig. 65. — Splint Applied for Traction. 

sits firmly upon the pad- 
ded strap." Dividing his weight between the sound 
limb and the splint, he doubtless has a composite 




THE. HIP SPLINT 115 

sensation of standing and fitting. In progression 
weight is thrown alternately on the splint, as in Fig. 
63, and on the well foot, as in Fig. 64. It is not en- 
tirely fanciful to say that the patient is sitting while 
walking. It is related that a little boy, to whom the 
splint was applied, walked about exclaiming: " I'm 
sitting down." When tired a patient may lean against 
some support and rest by sitting on the strap. Mr. 





b «*5"— " ^ — s^'c 

Fig. 66. — Application of Adhesive Plaster to Lim; 

Adams, returning to London in 1877, described chil- 
dren under treatment for hip disease walking about 
the streets and " enabled to get in and out of the 
tramway cars without difficulty." 

To Make Traction, strips of adhesive plaster may 
be attached to opposite sides of the limb and pro- 
tected by a reversed bandage. Drawing the turns of 
a roller and passing it under the limb are painful to 
a sensitive joint, from the necessity of raising the 
limb. This difficulty was overcome in Dr. Fayette 
Taylor's practice by the use of a legging of twilled 
muslin, seen in Fig. 65. It was slipped into place 
and laced without disturbing the limb. Dermatitis 
may appear under the plaster as the result of re- 
tained moisture, as it does under a continued poul- 
8 



ii4 GROWTH AND DEFORMITY. 

tice. It is said that a "wet pack" is sometimes 
artfully claimed to have a curative effect on rheu- 
matism and other complaints by drawing morbid 
matter to the surface in the shape of an eruption. 
The skin will escape irritation if one strip is applied 
antero-laterally, as at A in Fig. 66, and the other 
postero-laterally, as at B, leaving fresh areas for the 
reception of succeeding strips at C and D. 

When prehension of the limb is thus secured the 
leather straps seen in Figs. 60 and 65 maybe buckled 
to the plasters and the ischiatic strap adjusted on 
the pelvic band. Traction may then be made by 
propelling the rack with the pinion. If a high de- 
gree of traction is employed in warm weather, or in 
a hot room, the plaster will gradually slip down, 
when the leather straps may be buckled shorter and 
the plasters renewed sooner. Their removal may be 
facilitated with naphtha or some other solvent. A 
light plaster may be reenforced, before the buckles 
are stitched or eyeletted in place, by tape sewn on in 
parallel lines which will not prevent the removal of 
the facing just before application. Gum collecting 
on the needle of the machine may require a drop of 
oil. 

Traction is especially applicable to the victim of 
an advanced stage. Mr. Hancock's description in- 
cluded these words : " Look at a patient wasted to a 
shadow, confined to his bed for months and in the 



THE HIP SPLINT. 115 

last stage of exhaustion from long-continued dis- 
charge, his hands employed night and day inces- 
santly maintaining a fixed position of the limb, and 
endeavoring to prevent the intense agony which oc- 
curs on the slightest movement. Often have I seen 
the poor hip-joint patient, when all others have slept, 
still wakeful and anxiously engrossed with the one 
and monotonous task of steadying the knee and pre- 
venting movement." This graphic description was 
written in advocacy of exsection of the hip, an opera- 
tion of heroic surgery, described by a fanciful writer 
as "majestic and sanguinary." Continuing his argu- 
ment Mr. Hancock proceeds: "Look again at this 
patient; his position is no longer one of constraint 
and torture, it is one of comparative comfort and 
rest. He no longer suffers the extreme pain, he no 
longer exists in dread of the slightest movement or 
jar, his countenance loses its drawn and anxious ap- 
pearance, the hectic subsides and we have alleviated 
a very vast amount of suffering almost beyond the 
power of endurance." Mr. Hancock's description 
of the change wrought by exsection applies with 
exactness to that effected by traction or fixation. 

Details of Application in the Third Stage. — In this 
stage treatment may be promptly undertaken regard- 
less of the presence of abscesses, sinuses, or extreme 
deformity. The splint, being designed for a normal 
figure, throws the deformity into such marked relief 



u6 GROWTH AND DEFORMITY. 

that it seems impossible at the first view to proceed. 
With the upright of the splint lying against the ex- 
tremely adducted thigh, the pelvic band will neces- 
sarily extend obliquely across the recumbent trunk 
in front and behind. It will therefore be desirable to 
begin by using a perineal strap the length of which 
can be varied by attaching it by buckles screwed to 
the pelvic band. The strap will then be far from 
occupying the position directly under the ischiatic 
tuberosity which it would take if the limbs were sym- 
metrically disposed. It may even be applied at first 
to the unaffected side of the perineum. Thus, pro- 
ceeding slowly and with care, the instrument may 
be so arranged as to permit the employment of a 
slight amount of traction and counter-traction by the 
use of the key. This is at once attended by a partial 
and agreeable arrest of motion, followed immediately 
by commencing reduction of deformity. In a few 
days, or in a few hours, with freedom from pain and 
with returning sleep and appetite, and with fresh 
hope and confidence on the part of the patient, the 
case will be more easily managed. In a short time 
symmetry will be found to be so nearly restored that 
the pelvic band will cross the body transversely and 
the splint can be conveniently worn. The buckles 
may then be removed and the long strap may be 
discarded in favor of a suitably short one provided 
with loops for buttoning over the ends of the pelvic 



THE HIP SPLINT. 117 

band, which will thus be brought down to its proper 
position below the level of the iliac spinous processes. 
Flexion and adduction will have been seen to dimin- 
ish, the latter very likely giving way to abduction to 
such a degree as to cause anxiety from extreme ap- 
parent lengthening. This will in its turn diminish 
with the resumption of locomotion. 

Weight and Pulley. — The pain which attends this 
difficult stage calls for treatment with the least pos- 
sible delay. While the splint is being prepared a 
weight and pulley may be applied. If the pulley is 
attached to the wall of the room at a considerable 
height, the direction which the traction takes may be 
changed, with great convenience and without dis- 
turbing the patient, by rolling the cot toward or 
away from the wall or to one side or the other of 
the pulley. When deformity has been partly re- 
duced by the weight and pulley, treatment may be 
continued by the application of the splint. A vast 
amount of care and consideration may well be ex- 
hibited in the management of a case of this kind un- 
til the patient learns the use of the key, when happi- 
ness and contentment take the place of misery of an 
extreme type. Many years ago when mechanical 
treatment of this disease was under consideration in 
a children's ward at Bellevue Hospital, there were 
more hip cases than splints, and it was necessary to 
shift apparatus from less to more painful cases, 



n8 GROWTH AND DEFORMITY. 

which was always done with difficulty and as a cruel 
necessity, for the youngsters had learned to appreci- 
ate the comfort and convenience conferred by the 
new treatment. 

The patient in an advanced stage, and indeed in 
any stage, should have a liberal and varied diet. He 
will soon leave his bed and join his playmates. He 
becomes an office patient or, if treated at a hospital, 
an out-patient. Being equipped for painless locomo- 
tion, he is instructed in the acquisition of a symmet- 
rical gait characterized by normal rhythm in his 
footsteps. As he gathers strength and marches in 
military time it becomes evident that fixation is suffi- 
cient to save the joint from pain and to promote re- 
pair, but not so rigid as to check restoration of shape 
by the unconscious efforts of the patient to give to the 
limb an attitude convenient for locomotion. There 
will be days when the child will be overcome by lassi- 
tude, and nights of disturbed rest. Such interrup- 
tions, probably requiring medication, will diminish 
in length and frequency with the approach of re- 
covery. 

The relaxation of the leather straps, which is ob- 
served when the patient throws his weight on the 
splint, has the appearance of being a failure in the ac- 
tion of the apparatus. It is caused in various ways. 
It may be the result of making the whole splint so 
light that it bends under the weight, enough perhaps 



THE HIP SPLINT. 119 

to allow the patient's heel to rest on the foot-piece of 
the splint. It may also be caused by wearing the 
pelvic band too high, as shown in Fig. 67, where the 
curved line and the dotted line represent the perineal 
strap before and after the weight of the body falls on 
it, causing a descent from B to D and a correspond- 
ing slackening of the leather straps. Fig. 68 shows 
a comparatively slight descent from B to D effected 





b 

Fig. 67. Fig. 6S. 

Figs. 67, 63.— The Effect of a Long and of a Short Strap (1881). 

by lowering the band and shortening the strap. It 
has been suggested that in walking the limb is sub- 
jected to alternate traction and relaxation, and that 
the joint is thus exposed to a pumping process. It 
may be borne in mind, however, that the traction 
made by the use of the key when the patient is re- 
cumbent seldom equals that made by the weight o* 
the limb when the patient is erect. It is probable, 
therefore, that the joint can be pumped only by al- 
ternations of standing and recumbency. 

The Management of the Apparatus at Home may 
be governed by two rules, one of which calls for per- 



120 



GROWTH AND DEFORMITY. 



sistent separation of the heel from the ground, re- 
gardless of the tension or relaxation of straps when 

the patient is up, while the 
other prescribes that the straps 
shall automatically become 
tense when he lies down. The 
patient, if past the age of in- 
fancy, assumes control of the 
key himself, and he soon learns 
that the observance of the pre- 
scribed details secures conven- 
ience and freedom from pain. 
The splint thus applied is worn 
day and night, providing (i) for 
general health by exchanging 
the sick-room for out-of-door 
activity, (2) for arrest of mo- 
tion in acute stages, (3) for 
removal of weight from the 
joint ,in all stages, and (4) for 
locomotion with the limb in 
good position. In a favorable 
case a patient may be said to 
walk toward recovery cito, tuto, 
etjucunde. 

Traction to be Withdrawn. The Ischiatic Crutch. — 
When it is seen that the patient is indifferent to the 
use of the key it is a clear indication that he has 




Fig. 69. — Ischiatic Crutch. 
Seen also in Figs. 63 and 
64 on p. in (1887). 




THE I SCI 1 1 AT It CRUTCH. 121 

passed out of the acute stage in which traction was 
necessary and that the joint is tolerating motion and 
disturbance. The plasters may, however, remain on 
the limb and the splint may still be worn at night for 
a few weeks or until continued neglect of the use of 
the key makes it evident that traction, 
agreeable at first on account of its ano- 
dyne quality, has ceased to be desirable 
and useful and is not likely to be again 
required. The leather straps and the 
plasters to which they buckle may then 
be removed and the apparatus may be 

1 . J Fig. 7a— Splint 

laid aside at night. It is then useful shod with 

only as a protective splint and in due cather 

time it may be replaced by a simpler in- 
strument capable of being lengthened as the patient 
grows by the overlapping parts seen in Fig. 69. A 
joint is sometimes introduced in this splint at the 
level of the knee. A release provides for flexion at 
will and firm extension is made automatically. With 
the adhesive plasters and rack and pinion discarded, 
the upright may be shod with sole leather, in the 
manner seen in Fig. 70, or with any of the ordinary 
forms of crutch tip, one of which is seen in Figs. 64 
and 69. It is then practically a crutch, weighing 
from one pound and eight ounces to three pounds 
and eight ounces. In other respects the instrument 
is unchanged in its application and adjustment. It 



122 GROWTH AND DEFORMITY. 

is worn only when the patient is out of bed, as in 
disease of the knee or ankle, or in any chronic ail- 
ment in which one limb requires protection from the 
weight of the body. 

Comparative Importance of Traction and Protection. 
— It is an interesting question whether traction or 
protection is the more important feature of mechan- 
ical treatment. If the morbid foci were recognizable 
at their very beginning, protection, by converting the 
limb into a pendent member, might lead to resolu- 
tion with no further trouble and traction might sel- 
dom be called for. But the diagnosis is almost never 
made until painful symptoms demand traction, which 
is then extremely important as a means of relieving 
pain and promoting resolution by arrest of motion. 
It is required, however, but a comparatively short 
time in the long duration of a case. Protection, on 
the other hand, is necessary from the beginning to 
the end of the treatment. It is more indispensable 
than traction, since it provides for locomotion and 
ultimate symmetry and promotes resolution by ar- 
resting the most mischievous function of the joint, 
weight-bearing. 

While it would be difficult to treat urgent cases 
without resorting to fixation, the hope may be in- 
dulged that the application of traction, or of any 
other form of fixation, will in time become unneces- 
sary or unusual when improved methods of early 



THE ISCHIATIC CRUTCH. 123 

diagnosis shall have made it possible to induce reso- 
lution in the initial stage by the timely enforcement 
of protection. 

The significance of the Weight of the Body as a 
Factor in joint disease is established by a review of 
certain figures drawn from the reports of two ortho- 
paedic institutions for a given year, in which many 
more patients were treated for disease in the lower 
than in the upper extremity. The table follows: 

Lower Extremity. Upper Extremity. 

Hip 55S Shoulder 7 

Knee 207 Elbow 16 

Ankle 64 Wrist 3 

Total 829 Total 26 

At the first glance, it would seem that joint dis- 
ease is caused by the pressure and concussion which 
fall to the lot of the lower extremities, but this view 
is not in accord with the indication> of typical his- 
tories, which include tuberculous deposits in the can- 
cellous tissue, which of course may occur in any part 
of the skeleton. The correct inference is that foci in 
the upper extremity, where they are exempt from vio- 
lence, undergo resolution without symptoms or rec- 
ognition. This agrees with the fact that the dreaded 
tuberculous process, wherever it appears, owes its 
destructive quality to unfavorable environment, me- 
chanical and otherwise, and not to an inexorable dis- 
position of its own. Quiet resolution may hardly be 



124 GROWTH AND DEFORMITY. 

expected in the lower extremity which feels the press- 
ure of the weight of the body and the violence attend- 
ing locomotion, violence of great severity when the 
bones are called to withstand the successive blows 
which attend running and jumping. 

Disease of the Wrist, Elbow, and Shoulder. — When, 
as sometimes happens of course, tuberculosis of the 
joints assumes destructive activity in the upper ex- 
tremity it may be owing to the absence of desirable 
arrest of motion, and in some cases perhaps to pas- 
sive motion, or brisement force, prescribed for the pre- 
vention of ankylosis. Fixation may readily be made 
at the wrist by a plaster-of-Paris dressing or a simple 
supporting and restraining splint, on which the hand 
and forearm are confined by strips of adhesive plas- 
ter, leaving the digits free. Such an application re- 
stored the right wrist of a boy nine years old who 
was under treatment for purulent right hip disease, a 
sinus appearing on the palmar surface of the wrist in 
December, 1890, about six months after one devel- 
oped at the hip. There was disintegration of each 
joint with profuse and at times offensive discharge. 
The sinus at the wrist permanently closed in August, 
1892, one year after closure at the hip. In 1904 limi- 
tation of motion at the wrist was found only after 
careful comparison with the other wrist. If ankylosis 
at the elbow is unavoidable, it should be at an angle 
giving the best ultimate convenience in the use of 



THE ISC HI A TIC CRUTCH. 125 

the hand. A retentive splint at this point should 
give exact control. But a splint applied to control 
motion between the humerus and scapula will meet 
with the difficulty which is present at the hip-joint, ab- 
sence of efficient leverage above the point of motion. 
The ordinary methods of averting accidental disturb- 
ance of this joint and preventing undue use of the 
arm seem to afford sufficient fixation. Loss of mo- 
tion is concealed even more readily at the shoulder 
than it is at the hip, where vicarious mobility, in the 
spine and the other hip-joint, gives remarkable facil- 
ity in the use of the limb. The scapula is so loosely 
attached to the trunk that its joint with the humerus 
may be ankylosed with the retention of very wide 
use of the arm. In his paper on " Quiet Necrosi.s" 
Mr. Paget wrote as follows: "The most remarkable 
case was a boy of whom, though he had been care- 
fully brought up, it was never known that his left 
shoulder was completely stiff till he went to Eton 
and was found defective in some of the school games. 
The joint was immovable, the muscles around it 
wasted, but it was free from all signs of disease, and 
I fully believe always had been so; and, whatever 
had been the disease, it was now passed." The 
same good result follows intelligent expectation in 
cases of purulent disease of the shoulder-joint. 

Methods of Protection.— In joint diseases of the 
lower extremities the ever ready recumbent position 



126 GROWTH AND DEFORMITY. 

of course gives perfect protection from the traumat- 
isms inseparable from locomotion. Protection is also 
furnished by horseback and bicycle riding, either of 
which may be prescribed or allowed in suitable cases. 
For the very young the tricycle may be substituted 
for the more difficult machine. A more common 
resort is to a pair of crutches, the usefulness of which 
may be increased by the addition of a high sole to 
the well foot. Experiments are on record in which 
a high sole was added to the well side and a leaden 
sole was attached to the shoe of the affected limb for 
the purpose of increasing the traction which is nat- 
urally made by the weight of the limb when the pa- 
tient is erect. Dr. Norman Chapman advocated 
protection of the diseased hip by flexion of the knee 
in a silicate bandage in order to keep the foot from 
the ground. Mr. Brodie said: " The patient should 
never walk except with the assistance of a crutch," a 
precept that has been little regarded, crutches being 
usually considered not as a curative device but rather 
as aids to locomotion, or as insignia of the crippled 
condition. The older surgical works contain cuts of 
an ordinary crutch with a horn, or curved process, at 
a suitable level for receiving the ischium or the up- 
per part of the femoral shaft. An artificial limb often 
receives weight in the former region. Hip splints 
furnishing ischiatic support were described by Italian 
surgeons, and one carrying two perineal straps was 



THE ISCHIATIC CRUTCH. 



127 



figured in a surgical work published at Paris in 1853. 
Dr. Edmund Andrews was not unmindful of 
the superiority of ischiatic over axillary support 
in cases of chronic disease of 
the lower extremity. The instru- 
ment invented by him is repre- 
sented in Fig. 71. Dr. Prince de- 
scribed a brace to which he gave 
the name of ischiatic crutch in 
1866. An inexpensive form of 
Dr. Prince's splint is seen in Fig. 
72. The well-known "Dow" of 
Dr. Taylor has a convenient joint 
at the level of the knee. Axillary 
supports are conspicuous and easily 
forgotten or wilfully laid aside, 
while the ischiatic crutch cannot 
be readily taken off, leaves the 
hands and arms free, and is almost 
invisible under the clothing. The 
weight of the body supported in 
this way is felt, not in the un- 
stable and sensitive axillae, but on a 
solid and basilar part of the skel- 
eton, which is accustomed to weight bearing in sit- 
ting and walking. The ischiatic crutch seen in 
Fig. 63 has been used with convenience as an artifi- 
cial limb in a case in which cosmetic considerations 





FlG. 71 — Dr. Andrew 
Splint (1S60). 



128 



GROWTH AND DEFORMITY. 




were negligible. The ease with which it could be 
lengthened made it especially suitable for a growing 
child. It requires considerable time for a patient to 
learn to walk conveniently with this apparatus and 
for the perineum to tolerate the presence of the seat 
strap. Otherwise it would probably be frequently 
used in fractures and other 
acute cases requiring arrest of 
the function of one limb. 

Ununited Fracture, with its 
tedious duration, presents an 
emergency in which this instru- 
ment has been useful. This 
trouble seems to come to an end 
when the patient, unwittingly or 
by advice, exposes the fragments 
to irritation caused by the use of the limb im- 
perfectly protected from the corporal weight. The 
ease with which the amount of irritation may be 
varied by lengthening or shortening the splint sug- 
gests this as a practicable resort. 

Discontinuing the Treatment of hip disease is a mat- 
ter requiring the exercise of judgment and caution. 
It is of course better to continue treatment longer 
than is necessary than to desert the vantage-ground 
of protection too soon. The patient has become so 
accustomed to the splint, and has had so little incon- 
venience from its habitual use, that he is usually in no 



Fig. 72. — Dr. Prince's " Is 
chiatic Crutch" (1866). 



TREATMENT OF HIP DISEASE. 129 

haste to part with it. After a long course of protec- 
tion, and when the sinuses, if any have appeared, have 
been replaced by firm scars, the patient may be en- 
couraged to go without the steel crutch every day for 
a short time, which may be lengthened under judi- 
cious advice. Later the splint may be removed in 
the house, and reapplied when the patient goes out. 
Still later, he may be out of doors without the splint 
for a while each day, and then without it all day 
once or twice a week, and finally it may be laid 
aside entirely. A return to ischiatic support in wak- 
ing hours should at once follow a recurrence of 
symptoms. While gradual release from treatment is 
in progress, the patient should be observed and ad- 
vised from time to time until the joint is well. In 
exceptional cases, due to recurrence of disease or to 
mistaken judgment, there should be resumption of 
treatment with as much zeal and confidence as if the 
affection were beginning. After recovery, the pa- 
tient should avoid extreme exertion, such as moun- 
tain climbing, tramping with a gun, and long pedes- 
trian tours. An example of the bad effects of undue 
physical effort is seen in Case XI. recorded on pages 
152-154. It is a strange fact that many young people 
with more or less locomotor disability feel impelled 
to accept undertakings involving extraordinary en- 
durance and physical exertion. Their unreasonable 

ambition in this direction should be checked. 
9 



CHAPTER VI. 

ABSCESSES OF HIP DISEASE. 

In many cases the course of hip disease is diversi- 
fied by the appearance of sinuses, some of them the 
result of spontaneous eruption and others established 
by operations on swellings or diseased bone. It is 
not easy to draw a line between cases which have 
and those which do not have abscesses. Collections 
supposed to be purulent may happily disappear. 
Operations on bone sometimes leave sinuses with an 
indefinite flow in cases which would have shown no 
discharge if the knife had been withheld. Such in- 
stances may or may not be included in a compiled 
table of cases attended by abscesss. It is therefore 
difficult to say what percentage of patients have this 
complication. Is it an abscess when the fluid is con- 
fined in the cancellous tissue or in the cavity of the 
joint, or only when it gathers enough volume to re- 
turn fluctuation, or only when it appears on the sur- 
face ? These questions would be more significant if 
abscesses were more important features of joint dis- 
ease than they are. 

When abscesses appear as tumors, and especially 

130 



ABSCESSES OF HIP DISEASE. 131 

when they discharge, they are much dreaded in the 
popular mind, but in practice the management of the 
affected bone in which they rise claims chief atten- 
tion. They show caprice in their early or late ap- 
pearance, their number, their location, and in their 
deportment. 

COLD ABSCESSES. 

Case VI. — Cold Abscess. — A girl seven years old, 
when first seen in December, i88i,had suffered from 
disease of the right hip for one year. Nine months 
later a fluctuating tumor appeared without interfer- 
ence with health and activity. In two months, hav- 
ing reached a great size, it opened on the anterior 
and upper part of the thigh when she was sweeping 
the sidewalk with a toy broom. There was a torrent 
of fluid containing flakes of caseous matter. Col- 
lapse of the tumor was followed by a varying dis- 
charge for seven months, which ceased with the 
formation of a scar. Seven months later moisture 
reappeared, and for eighteen months there was a suc- 
cession of small scabs followed by a scar which, in 
1898, was attached to the bone. This abscess was 
attended by no general disturbance, and caused no 
pain or loss of blood. Other cases followed a similar 
course. 

In 1879 a girl of the same age had a large collec- 
tion of matter on the inner side of the thigh present- 



132 GROWTH AND DEFORMITY. 

ing at its summit a small area of insensible skin 
which she broke with a pin, while playing in the gut- 
ter. Fluid escaped in a jet followed by collapse of 
the tumor and the formation of a scar five months 
later, which in 1885 was depressed and attached to 
the bone. 

A boy five years old, in 1883, presented a fluctuat- 
ing tumor extending from the trochanter to one inch 
above the patella, which opened during sleep. He 
thought he had wet the bed. The sinus alternated 
between eruption and closure for fiwe and one-half 
years, leaving a scar which was firm and bleached in 
1898. The position of the limb in this case is de- 
scribed on page 179. 

Case VII. — Cold Abscess. — A girl four years old, 
when first seen in October, 1883, na cl suffered from 
symptoms of disease of the left hip for several weeks. 
The usual signs of the disease were present except 
that measurements failed to reveal wasting of the 
limb, the thighs being equal in circumference. Fif- 
teen months later fluctuation was found by palpa- 
tion, extending downward two inches and a half from 
the trochanter, and the measurements were as fol- 
lows: Left upper thigh, 12^ inches; lower thigh, 
8>^ inches; leg, 8/^ inches. Right upper thigh, 12^ 
inches ; lower thigh, 9^ inches ; leg, 8H inches. At 
this stage the affected thigh often measures between 
one and two inches less than the well one. Its size 



ABSCESSES OF HIP DISEASE. 133 

in this case was maintained by the presence of a deep 
collection of fluid. Fluctuation slowly disappeared 
and although the limb slightly increased in size with 
the growth of the child, it failed to keep up with the 
well limb. At a later date the measurements were: 
Left upper thigh, 13^ inches; lower thigh, 9^ 
inches; leg, 9^ inches. Right upper thigh, 15^ 
inches; lower thigh, u# inches; leg, g 3 4 inches. 
Treatment ceased in March, 1888. There were no 
other abscesses. The patient recovered and was 
last seen in September, 1890. 

In a similar case a girl three years old presented in 
1887 a fluctuating tumor on the anterior and outer 
side of the thigh at the junction of its middle and 
upper thirds. It reddened and pointed, and an erup- 
tion was predicted. The tumor decreased, however j 
and was gone six months after its appearance, leav- 
ing a dimple, seen in 1893, twenty months after treat- 
ment had ceased. The pit was evidently caused by 
the entanglement of fasciae in deep scar tissue. It 
was depressed as the child gained in flesh. Occa- 
sionally a patient receives a scar without the appear- 
ance of a trace of moisture or fluid. A wide area of 
skin covering a fluctuating tumor becomes indurated 
and thick. At one point it thickens more and more 
until a substantial and prominent scab forms. Fluc- 
tuation slowly disappears and a depressed scar is left 
resembling that which follows ordinary spontaneous 



134 GROWTH AND DEFORMITY. 

eruption. In all these cases it was not difficult to 
take an expectant attitude, which was justified by 
the results. The matter made a harmless exit or dis- 
appearance. Such a collection adds nothing to the 
duration of the disease and compromises the result in 
no way. The diseased bone recovers, unmindful of 
the deportment of the soft parts. Unfortunately, 
very few of the abscesses of hip disease act in this 
way. They are often attended by pain and general 
disturbance. 

INFLAMED ABSCESSES. 

Case VIII. — Cold,, followed by Inflamed, Abscess. 
— A boy four years old, when first seen in Novem- 
ber, 1879, had suffered from disease of the right hip 
for one year. Fifteen months later a cold abscess 
appeared and grew until it occupied the upper two- 
thirds of the outer side of the thigh, distending the 
boy's trousers. It decreased and could not be found 
twenty-one months after its appearance. The tis- 
sues were condensed and three months later, without 
a return of fluctuation, a sinus opened on the outer 
side of the thigh with pain and general reaction. 
Alternations of eruption and quiescence were ob- 
served for several years, but without interference 
with the patient's activity, until the case was lost to 
observation. 

Abscesses were attended by severe local and gen- 



ABSCESSES OF HIP DISEASE. 



135 



eral symptoms in the case of a boy seven years old. 
The first one was incised on the inner side of the 
thigh in January, 1875, an d was followed by three 



m? 



>\ It. Ml /l 

Fig. 73- Fig. 74- 

Figs. 73, 74. — Place and Order of Sinuses in Case XIII. (p. 158). 

sinuses on the outer surface and in the groin. Their 
places and order of appearance are shown in Figs. 73 
and 74. The swellings were hot and painful and oc- 






Fig. 75. Fig. 76. 

Figs. 75, 76. — Place and Order of Sinuses in Case XII. (p. 154). 

cupied wide areas of infiltrated tissue. When at 
their worst they caused distress and debility, with 
hectic, febrile temperature, failure of appetite, dis- 



136 GROWTH AND DEFORMITY. 

turbed sleep, and wasting. At such times the boy, 
up and dressed daily, moved about with crutches and 
a splint with which he maintained comfortable trac- 
tion. In the intervals he discarded crutches and was 
out of doors. After two years the sinuses perma- 
nently closed leaving scars, which twenty-four years 
later were found attached to the bone (Case XI II., p. 
158). A group of abscesses similar in character and 
effect appeared in the thigh and groin in the case of 
a girl three years old, as seen in Figs. 75 and 76. 
They complicated the progress of the disease from 
March, 1878, to September, 1879, as is recorded in 
Case XII. (pp. 154, 157, and 158). 

Case IX. — Inflamed Abscesses. — A girl seven years 
old, when first seen in January, 1883, had suffered 
from disease of the left hip for three years. A sinus 
following an incision had been open on the anterior 
and upper part of the thigh for five months. Six 
months later it closed with a firm scar. At the end 
of two years and three months it reopened and closed 
again after a few months. This was repeated three 
times between October, 1885, and August, 1895. On 
each occasion the gathering was marked by local dis- 
tress and febrile prostration. Fragments of bone 
were found in the matter. In the intervals her 
health and ability were restored to such a degree that 
while under treatment she acquired a practical 
knowledge of vocal music of which she made sue- 



ABSCESSES OF HIP DISEASE. 137 

cessful use. Her ability to walk without lameness is 
described on page 160. In 1904 the scar had been 
bleached and attached to bone for nine years and 
was probably conclusive. 



TREATMENT. 

The management of a case including inflamed 
abscesses is beset with difficulties. A knee thus af- 
fected was formerly thought to require amputation. 
The general rule which advises the free and early 
incision of all abscesses is recalled, but its authority 
is weakened by a mental picture of the liquefying 
bone which gives rise to the matter. The urgency 
of the symptoms may seem to call for an incision 
which with due preparation is considered in any 
event harmless, unless it meets the objection that it 
surrenders the protection provided by encysting mem- 
brane and gives purulent matter access to divided 
vessels. Much benefit can hardly be expected to fol- 
low the opening of an abscess when it is learned by 
experience that the date of the final closure of the 
sinus is not thus hastened or the course of the dis- 
ease modified in any other way, effects not to be rea- 
sonably expected in view of the facts that incision has 
no control over the status of the bone and that the 
step is taken very late in the history of the abscess. 
A bistoury skilfully directed in an early stage might 



138 GROWTH AND DEFORMITY. 

release matter painfully imprisoned in cancellous tis- 
sue, and thus shorten the disease and conserve bone ; 
but when pus has broken through the compact shell 
and lies in the cellular structures, or in the cavity of 
the joint, events may not be controlled by local inter- 
ference of this kind. If the abscess is cold there is 
no painful tension ; if hot, the tension of infiltrated 
tissues can be relieved only by multiple incision. In 
either case artificial closure is sought with difficulty, 
and when found is inferior to natural sealing, and, 
with the observance of all due precaution, nothing is 
gained by incision unless the purulent depot is 
scrapecl, and then nothing unless affected tissue of 
all kinds is removed and the foci extirpated, which 
implies in many cases excision of the joint or large 
portions of bone. An operation, of either minor or 
major surgery, does not bar the necessity of mechan- 
ical treatment, which applied to the bone early or late 
will ensure a recovery, with or without an opera- 
tion, by the slow but sure process of natural repair. 
For many years the suggestion that the abscesses of 
joint disease might well be intelligently neglected has 
found frequent expression in literature. It may in 
due course of time receive general assent. 

The appearance of an abscess is sometimes useful 
because it leads to cheerful acceptance on the part of 
the patient of the inconvenience of prolonged treat- 
ment, the necessity of which is clear only to the 



ABSCESSES OF HIP DISEASE. 139 

physician, who needs no such reminder of the seri- 
ous condition of the bone. But when an eruption 
occurs, indifference is apt to be replaced by undue 
anxiety concerning what is thought to be the most 
serious incident of the case, but which is really little 
more than a complication requiring the observance 
of customary sanitation. An established sinus is 
painless and resembles the natural openings lined 
with mucous membrane, and the region readily tol- 
erates disturbance and even violence. 

Significance of Abscesses. — It is difficult to explain 
the appearance or non-appearance of this complica- 
tion except by the inconsequent statement that caries 
may be dry or moist. It is probable that the selec- 
tion depends on the diathesis, or something liable to 
change in the patient's general condition, rather than 
on any local change brought about by treatment or 
otherwise. Continued suppuration has been thought 
to lead to visceral degeneration ; but this relation has 
not been established, it being questionable which is 
the cause and which is the effect. When there is a 
failure of general health coincident with continued 
suppuration it is probable that the former is the cause 
of the latter. 

Origin of Abscesses and Location of Sinuses. — 
Many attempts have been made, but without notable 
success, to drain the region of initial foci by working 
a tunnel through the neck of the femur by way of 



140 GROWTH AND DEFORMITY. 

the subcutaneous surface of the great trochanter. It 
is not easy to ascertain the starting-point, or route, 
of an abscess. Matter found in the cavity of the 
joint may be composed of caseous debris diluted with 
products of synovitis. If collections occur without 
communicating with the joint, the matter must have 
perforated the compact shell at a point beyond the 
attachment of the capsule. Severe pain in the early 
stage, unrelieved by traction and fixation and sud- 
denly ceasing, has been thought to be caused by mat- 
ter confined for a while under tension in the cancel- 
lous tissue and to presage a palpable collection of 
fluid. When the latter has gained headway it takes 
the shortest route to ihe surface modified by gravity 
and the lead of muscular and other sheaths. Thirty- 
five per cent, of sinuses have been observed on the 
anterior, twenty-seven per cent, on the outer, and 
twenty-five per cent, on the posterior surface of the 
hip and thigh, and thirteen per cent, on the inner 
surface of the thigh. They do not often interfere 
with the application of the hip splint, which makes 
distinct pressure only where the ischiatic and pubic 
bones rest on the supporting strap. The scars which 
follow the abscesses of hip disease may be attached 
to the femoral shaft, to the great trochanter, to the 
horizontal ramus of the pubes, to Poupart's ligament, 
to the sacrum, and to the crest and anterior and pos- 
terior superior spines of* the ilium. They give a re- 



ABSCESSES OF HIP DISEASE. 141 

markably dimpled or tufted appearance, especially in 
those who are inclined to be fat. 

When exanthemata intervene in the course of 
purulent hip disease the affected area shares in the 
cutaneous disturbance, with intense redness, and a dif- 
fused swelling which gives to the sinuses the appear- 
ance of cloacae, or caverns emitting copious thick 
pus. It is a common observation in cases of long- 
continued discharge that the patient suffers loss of 
appetite, lassitude, and other febrile indications when 
the flow ceases for a time, and that these symptoms 
disappear when the discharge recurs. When healing 
of the bone shuts off the supply of matter the part 
assumes a saucer-like depression, at the bottom of 
which a scab is followed by a scar attached to deep 
fasciae or to bone. The order in which sinuses close 
is not necessarily that in which they open. The last 
to close is that leading from the point or area of bone 
which is the last to cicatrize. 



CHAPTER VII. 

DIAGNOSIS, PROGNOSIS, AND APPRECIATION OF 
RESULTS OF HIP DISEASE. 

DIAGNOSIS. 

Two diagnostic reminders, important in general 
practice, find expression in these words : The pain of 
hip disease is in the knee and the pain of spine dis- 
ease is in the stomach. Recurring Pain in the Knee, 
in the absence of physical evidence of disease of this 
joint, should call attention to the condition of the 
hip. But pain, except as an alarm, is not an important 
indication. It belongs to the group of subjective 
symptoms which may be almost entirely disregarded 
in making a diagnosis of an affection which displays 
so many signals. 

Inconstant Lameness. — Among the first signs is 
lameness, which may disappear, to return after an 
interval of days or weeks ; it is present in the morn- 
ing when the patient leaves his bed and wears off 
after a brief period of activity ; it breaks up the nat- 
ural rhythm of walking, in which equal time is given 
to the two feet, leaving the well foot on the ground 
longer than the affected one, and leading the former 
to give a more accentuated stroke as it hastens to re- 

142 



DIAGNOSIS OF HIP DISEASE. 143 

lieve the latter from the weight of the body. Akin 
to lameness is the attitude at rest, in which the pa- 
tient habitually stands favoring the affected limb 
which assumes marked Adduction and slight flexion, 
while the weight is principally thrown on the well 
limb. Next to lameness in the order of obviousness 
is Muscular Atrophy, owing partly perhaps to reflex 
interference with nutrition and seen in a flat natis as 
the patient stands, and in the description of the gluteal 
fold, which is shorter and more shallow and depressed 
than that of the well side, and in the reduced circum- 
ferences of the thigh and leg. 

Reflex Muscular Action. — Next in turn comes the 
most valuable sign of the early stage, interference 
with passive motion by reflex muscular action. The 
muscles are said to be on guard. Verneuil used the 
expressive term vigilance musculaire in a graphic 
description of this peculiar action or condition of the 
muscles which, while common to all diseased joints, 
is best seen in the hip, because a ball-and-socket joint 
depends especially on its muscular system for both 
motion and stability. It is a sign especially valuable 
when lameness is inconstant, atrophy equivocal, and 
the pain referred to the knee. It is also significant 
in convalescence. It is found earliest in rotation. 
Let the patient sit with the legs hanging over the 
edge of a table and then impart a lateral pendulum- 
like motion to the foot and note whether the arc 



144 GROWTH AND DEFORMITY. 

of motion is less on the suspected side ; or when the 
patient is supine impel the limbs, one at a time, giv- 
ing them a rolling motion outward and inward. On 
the well side the outer and inner borders of the foot 
will strike the table, or nearly so, while on the affected 
side rotation will be limited. The patient may be in- 
duced to apply a test for limited passive flexion by 
grasping the shin and kissing the knee. On the sus- 
pected side he may not be able to bring the knee to 
the mouth. These tests should be made with delib- 
eration and gentleness, the object being to detect 
very slight differences in muscular action, or even to 
recognize reluctance of the muscles to relax in cer- 
tain directions, although they may not yet by their 
tonic action prevent wide motion. Aside from this 
reflex interference with passive motion, it is inform- 
ing to note the deportment of the adductors of the 
thigh under palpation. When passive motion is at- 
tempted they may exhibit a momentary spasm or else 
maintain a tonic contraction until the limb is re- 
leased, when they recover relaxation; or the abdomi- 
nal muscles, as well as the adductors, may show a sin- 
gle reflex spasm at the beginning of passive motion in 
any direction. These muscular indications should be 
sought in both limbs for the sake of comparison. To 
examine both sides is a rule of general application 
which it is never safe to neglect. A young physi- 
cian, after a great variety of advice sought relief from 



DIAGNOSIS OF HIP DISEASE. 145 

disability caused by what was believed to be a badly 
united fracture of the fibula. The supposed faulty 
callus was the prominent triangular subcutaneous 
area at the lower part of the bone. When a similar 
prominence was found in the other leg the imagined 
symptoms and the patient's apprehensions disap- 
peared. 

A Useful Diagnostic Sign has been described by Dr. 
Steele as a " brawny thickening about the joint in 
front of the capsule, or behind the trochanter." In 
the vicinity of inflamed bone a condensation of the 
soft parts may be found, not visible, but recognized 
by palpation or pinching, and then not clearly dis- 
cerned except by comparison of the two sides. A 
smaller pinch of skin and underlying tissue can be 
made on the well than on the affected side. None 
of the usual diagnostic signs may be deemed conclu- 
sive by itself. They are to be considered in com- 
bination and with due regard to other conditions 
which produce similar phenomena. They may be- 
tray hip disease in a patient as yet free from pain 
and lameness. 

Unmistakable Signs. — In a later stage, and when 
the disease is established, these minor points may be 
neglected because overshadowed by these three un- 
mistakable and easily read signs: (1) constant lame- 
ness; (2) marked disparity in circumferences, due 

not only to disuse of one side, but also to overuse of 
10 



146 GROWTH AND DEFORMITY. 

the other; and, (3) absence, or almost complete ab- 
sence, of motion in the joint. A combination of 
these salient features makes a picture of hip disease 
which is not easily mistaken. In regard to the first 
and the second there is little to be said, but the ab- 
sence of motion may escape detection, movements 
in the joint itself being so closely imitated by vicari- 
ous mobility of the lumbar vertebrae and of the other 
hip. The absence of motion, or the amount of mo- 
tion if some be present, may be recognized by notic- 
ing the deportment of the pelvis when attempts at 
passive motion are made. 

To Discover Lateral Motion, the patient lying con- 
veniently on a table which is set parallel with the 
wall of the room, give the limb passive abduction and 
adduction until the iliac spinous processes are square. 
If passive motion thereafter disturbs the direction of 
the line connecting the iliac spines there is no motion 
in the joint. If there be some motion in abduction or 
adduction, there will at first be no disturbance of the 
iliac spines and the extent of motion will be indicated 
by observing the point in the arc of abduction or ad- 
duction at which the iliac spines are disturbed. 

To Discover Antero-posterior Motion, raise the limb 
until the lumbar spinous processes rest on the table. 
If passive flexion or extension of the elevated limb 
disturbs the spinous processes there is no motion in 
the joint. If there be some motion there will be at 



DIAGNOSIS OF HIP DISEASE. 147 

first no disturbance of the spinous processes and its ex- 
tent will be indicated by observing the point in the arc 
of flexion or extension at which disturbance occurs. 

Structural Shortening. — While apparent shortening, 
caused by fixation or ankylosis in a bad position, is 
an almost conclusive sign of hip disease, structural 
shortening has but little diagnostic significance. It 
occurs in acute epiphysitis, which is a furious idio- 
pathic, or non-traumatic, inflammation, producing, 
not fixation, but the relaxation and eversion of dias- 
tasis, the preternatural longitudinal mobility of con- 
genital dislocation, and to some extent the disability 
and atrophy of infantile paralysis. As traumatism 
is not a factor of inflammatory joint disease, it is 
probable that a so-called diastasis with suppuration 
is usually an instance of acute epiphysitis. A differ- 
ential diagnosis between the results of epiphysitis, 
diastasis, single congenital dislocation, infantile paral- 
ysis, coxa vara, and hip disease is sometimes a mat- 
ter of difficulty. As the first is a profusely purulent 
affection, the presence of a scar is generally a con- 
clusive indication. As an exception, no scar was 
found in the patient whose shortening is seen in 
Figs. 108 and 109 (p. 181), but matter had found exit 
in great quantity by the vagina. 

Congenital Dislocation of the Hip. — This is a rare 
and painless deformity, almost never recognized unti? 
the child begins to walk. It does not interfere with 



148 GROWTH AND DEFORMITY. 

efficient locomotion and has no reaction on health, 
physical endurance, or longevity. It responds indif- 
ferently to treatment of any kind. When double it 
produces an easily recognized "sailor" gait. When 
single, lameness may be largely nullified by the as- 
sumption of the equine position of the foot and the 
normal rhythm of locomotion. 

Coxa Vara. — Many patients have probably received 
routine treatment for hip disease in whom reflex 
muscular signs were absent and whose trouble arose 
from coxa vara, or bending of the femur, which re- 
ceives the weight of the body at a disadvantage as it 
falls in a direction not parallel with, but oblique to, 
the axis of the neck 'of the bone. Whatever may be 
the cause of this weakness of the skeleton, while it 
exists the relief of the affected limb from weight-bear- 
ing is desirable. If bending of the bone goes to the 
extreme of producing serious deformity and disabil- 
ity, osteotomy will be necessary and promises satis- 
factory results. 

Synovitis after typhoid fever may simulate hip 
disease. A recent convalescent from typhoid pre- 
sented limited motion and a distended capsule of the 
hip-joint. Osteitis was excluded by the history and 
the absence of reflex contraction and local muscular 
wasting. The patient was warned against undue dis- 
turbance of the joint and recovered without disloca- 
tion or any special treatment. 



PROGNOSIS OF HIP DISEASE. 149 



PROGNOSIS. 

As hip disease is not in the category of affections 
likely to prove fatal, prognosis concerns itself almost 
entirely with the degree of resulting deformity and 
disability. At the very beginning, prognosis is 
largely a question of the date of the diagnosis. If 
this is made sufficiently early, treatment may fortu- 
nately induce resolution before the destructive proc- 
ess is under way. The tuberculous deposits may be 
absorbed or harmlessly desiccated, and the usual de- 
formity and functional impairment may be entirely 
prevented. These effects seem to have followed 
early diagnosis and treatment in the following in- 
stance : 

Case X. — Incipient Hip Disease. — A girl seven 
years old and apparently in perfect general health 
had symptoms for twelve weeks which led Dr. Ross, 
her physician, to a diagnosis of disease of the left hip. 
The history included night cries following days of 
unusual exercise, inconstant pain in the knee, and 
lameness with long intervals in which the child's gait 
was normal. Rheumatism was excluded. The fol- 
lowing signs were seen on October 25th, 1900: Ful- 
ness of the groin, flattening of the natis, a shallow 
gluteal fold, atrophy measuring one-half of an inch and 
one-quarter of an inch in the thigh and leg, and limi- 



150 GROWTH AND DEFORMITY. 

tation of motion by reflex muscular action when the 
extremes of passive motion were approached. On 
November 15th, 1900, an ischiatic crutch was applied 
for the protection of the limb, with a high sole on the 
well foot, and on the following day the patient was 
presented to the Orthopaedic Section of the New York 
A cademy of Medicine. The splint allowed the an- 
terior part of the foot to reach the ground. The toe 
could have been kept clear by increasing the thick- 
ness of the high sole and lengthening the splint. 
This would have increased the inconvenience of the 
application and was unnecessary in view of the fact 
that pressure transmitted from the toe by way of the 
ankle-joint and the' resistant muscles controlling the 
tendo Achillis was insignificant when compared with 
concussion passing directly through a bony column 
from the child's heel to the hip. Traction was post- 
poned because it was hoped that reflex muscular ac- 
tion would cease when inflammation was subdued by 
arrest of weight-bearing. If pain had required atten- 
tion, fixation would have been enforced by the addi- 
tion of traction. The recumbent position would have 
more thoroughly protected the joint, but the steel 
crutch was sufficient, as it practically put the limb 
to bed, while the child was up and going to school. 
The object of treatment was to promote the resolu- 
tion of subacute inflammation by relieving the limb 
from the duty of weight-bearing and the labor of 



INCIPIENT HIP DISEASE. 151 

locomotion, with the hope that absorption or harm- 
less incarceration would take place in a year or two 
years. Treatment continued for one year, and when 
the patient was again presented to the Section on 
December 20th, 1901, the only indications of previous 
trouble were shortening of three-eighths of an inch, 
and a want of symmetry not exceeding one-fourth of 
an inch in the circumferences of the thigh and leg. 
A favorable artificial environment had encouraged 
natural resistance to disease and extinguished the 
foci which otherwise would have broken into flame. 
When examined in September, 1904, the child was 
in excellent health and free from the signs and symp- 
toms of any joint disease. 

Reports of similar results following early diagnosis 
would be more common, if there were less reluctance 
to pronounce so serious a decision on an active and 
apparently well child. A more common history in- 
cludes a record of rheumatic pain, and time passed 
in waiting for an outbreak of startling signs. For a 
long time pain was thought to be an essential feature 
of early hip disease. This view was held by an old- 
fashioned physician who said that he had pounded a 
patient's heel at every visit until his efforts elicited ex- 
pressions of pain. It is related that, many years ago, 
a boy returning from a clinic explained that he had not 
cried so much as on previous occasions because he 
had given to the professors the other leg to examine. 



152 



GROWTH AND DEFORMITY. 



As an early diagnosis and complete recovery are 
not often recorded, prognosis as a rule deals with the 
question of how badly the patient will be crippled. 





Fig. 77. Fig. 78. 

Figs. 77, 78. — Case XL Third Stage, Six Months After Treatment, Age 

Nine Years. 

In many cases treatment is begun late, and in others 
it falls short of full control of the disease. Histories 
of patients in the third stage always present inter- 
esting features. 

Case XI. — Third Stage of Hip Disease. — A boy 
six years old had suffered from disease of the right 



INCIPIENT HIP DISEASE. 



153 



hip for nineteen months. The primary abscess 
opened spontaneously in February, 1877, on the day 
the patient was first seen. His local symptoms were 
acute and his general condition was greatly depressed. 
Exsection had been advised. Treatment continued 
two years and five months. Six months after it had 
ceased photographs were taken, as seen in Figs, yj 
and 78. Figs. 79 and 80 show the place and order of 
the sinuses. Locomotor ability was favored by the 
position of his limb, which was moderately flexed, but 
not adducted or abducted. His adult condition, 
twenty years later, is seen in Figs. 81 and 82. The 
outlines of his feet are shown in Fig. 83. In the ab- 
sence of advice he had for twelve years operated and 
furnished the power for a paper-ruling machine, 





Fig. 79. Fig. So. 

Figs. 79, 80. — Place and Order of Sinuses in Case XI. 



standing ten hours a day. He also became an expert 
bicyclist with a record for distance. This restless 
activity in work and recreation probably induced re- 



154 GROWTH AND DEFORMITY. 

current caries of the shaft with added shortening, 
which was- largely neutralized by the equine position 
of the foot as seen in Figs. 81 and 82. 





Fig. 81. Fig. 82. 

Figs. 81, 82. — Case XI. Third Stage, Twenty Years After Treatment, 

Age Twenty-nine Years. 

Case XII. — Third Stage of Hip Disease. — A girl 
three years old had suffered from disease of the right 
hip for one year. Her mother, her grandmother, and 



THIRD STAGE OF HIP DISEASE. 155 




Fig. 83. — Case XI. Feet at Nine Years and Twenty-nine Years. 




Fig. 84. 




Fig. 85. 



Figs. 84, 85.— Case XII. Third Stage, Eight Months After Treatment, 
Age Five Years. 



i 5 6 



GROWTH AND DEFORMITY. 




Fig. 86. — Case XII. Feet at Five Years and Twenty -five Years. 




Fig. 87. 




Fig. 88. 



Figs. 87, 88.— Case XIII. Third Stage, Eighteen Months After" Treat- 
ment, Age Twelve Years. 



THIRD STAGE OF HIP DISEASE. 



157 



several uncles and aunts had died from pulmonary 
tuberculosis. Treatment, begun in October, 1876, 





Fig. S9. 



Fig. 90. 



Figs. Sg, 90. — Case XIII. Third Stage, Twenty Years After Treatment, 
Age Thirtv-two Years. 



continued two years and seven months. The result, 
eight months after treatment of this patient ceased, 
is seen in Figs. 84 and 85. Her condition was prac- 



158 GROWTH AND DEFORMITY. 

tically the same twenty years later. The place and 
order of the sinuses are shown in Figs. 75 and 76 (p. 
135). The outlines of her feet are shown in Fig. 86. 
Case XIII. — Third Stage of Hip Disease. — A boy 
seven years old had suffered from disease of the right 
hip for four years. Treatment, begun in September, 





Fig. 91. — Case XIII. Feet at Twelve Years and Thirty-two Years. 

1874, continued four years. His condition eighteen 
months after treatment ceased is seen in Figs. 87 and 
88. The place and order of the sinuses are seen in 
Figs. 73 and 74 (p. 135) and his adult condition in 
Figs. 89 and 90. The outlines of his feet are shown 
in Fig. 91. 

Functional Results After the Third Stage. — In each 
of these patients nothing was wanting to make a 
typical presentation of the severest form of hip dis- 
ease. The cases, are instructive because they show 
that fairly good results may follow treatment begun 
in the third stage. They are not cited to show the 
superiority of the instruments used. Similar results 



THIRD STAGE OF HIP DISEASE. 159 

may be obtained by the use of any apparatus, 
whether it is recommended by authority or devised 
to meet the conditions of an immediate case, pro- 
vided it recognizes the necessity of fixation, protec- 
tion, and convenient locomotion. Patients who are 
not seen until the disease is far advanced cannot be 
taken to represent typically the advantages of treat- 
ment. Better results are seen when timely treatment 
anticipates the third stage, while the best are re- 
corded only in histories beginning with an exception- 
ally early diagnosis. These cases have the rather 
rare advantage of graphic comparison between re- 
sults immediately after and many years after the ces- 
sation of treatment. They illustrate the contributions 
made to symmetry and ability by growth and care- 
fully directed development. They show that excel- 
lent functional restoration may be expected in appa- 
rently hopeless cases. They confirm the opinion 
that confident reliance may be placed on intelligent 
expectation in the management of the disease and its 
complications. Although joint motion was practi- 
cally abolished in these cases they call to mind Mr. 
Hilton's patient, whom he describes thus: "She is 
an excellent dancer, frequently dancing for a whole 
evening, and but few persons know, when she sits 
down, that the right knee-joint is bent at right angles 
with the thigh and body, and tucked under the chair 
to meet the inconvenience of her fixed hip-joint." 



160 GROWTH AND DEFORMITY. 

The patient whose abscesses were described in Case 
IX. (p. 136) appears as a soloist without defect in her 
gait, although her structural shortening measures two 
inches. Another patient, who formerly disturbed 
his neighbors by night cries, is a popular comedian, 
concealing his lameness, or making it a grotesque 
feature at will, so that friends do not know whether 
he is really lame or not. Such cases are sufficiently 
common and well known to encourage the systematic 
instruction of patients in the study and practice of 
methods of circumventing deformity in the early 
years of life, when habits are formed and growth is 
an important element in the introduction of func- 
tional ability. 

MATHEMATICAL APPRECIATION OF RESULTS 
OF TREATMENT. 

The note-book of an orthopaedic clinic contains not 
many cases of the third stage, and fewer cases still in 
which early treatment has shut out all traces of dis- 
ease. When comparing results in ordinary cases the 
degree of joint motion seems at the first view to be 
of the greatest importance. When the range of mo- 
tion is wide the patient of course derives from it con- 
siderable benefit, especially when the arc of antero- 
posterior motion is wide enough to favor sitting and 
walking. 



RESULTS OF HIP DISEASE. 161 

Amount of Motion Less Important than Position of 
Limb. — A slight degree of motion, however, is but 
little better than immobility, and as a large propor- 
tion of patients have either slight or practically no 
motion, it is found that the position of the limb, 
whether adducted, flexed, or abducted, is the point of 
chief interest and importance. If the joint must be 
almost or quite motionless the presence of moderate 
flexion is desirable as it favors sitting and does not 
seriously interfere with walking. Adduction is al- 
ways deplorable because it is equivalent to apparent 
shortening which is often superimposed on real short- 
ening from loss of bone and disproportionate growth. 
On the other hand abduction is always desirable be- 
cause it is equivalent to apparent lengthening, which 
may compensate, in part at least, for real shortening. 
The idea that absence of mobility from the hip-joint 
precludes locomotion is not found in the mind of the 
physician, who recognizes the fact that vicarious mo- 
tion in the other hip and in the spine offers a com- 
pensation which is attended by effective and in favor- 
able cases almost normal locomotion. 

Mensuration of Deformity. — Orthopaedic practice is 
interesting especially because it deals with what is 
real and tangible. Physical demonstration is a part 
of daily routine. Pathological doctrines lie partly in 
the domain of physics and may be proved or dis- 
proved clinically, with mathematical certainty, and 
ii 



1 62 



GROWTH AND DEFORMITY. 



therapeutic plans are worked out by the application 
of mechanical laws. Subjective symptoms give way 
to objective signs, and at the end of treatment the re- 





Fig. 92. — Symmetrical 
Position. 



Fig. 93. — Abduction. 






Fig. 94. — Apparent 
Lengthening 



Fig. 95. — Adduction. 



Fig. 96. — Apparent 
Shortening. 



Figs. 92-96. — Mr. Marsh's Drawings, 1877 

suit may be expressed in fractions of an inch and de- 
grees of a circle. In Figs. 92 to 102 the methods of 
observing and recording the phenomena of a case 



RESULTS OF HIP DISEASE. 



163 



of hip disease seem to approach the details of exact 
science. The well-known drawings of Mr. Marsh, 
which are reproduced in Figs. 92 to 96, require no 
explanation. The images seen in Figs. 97 and 98 
are common dolls whose joints have been recon- 
structed in such a manner as to enable their limbs to 




Fig. 97. — Flexion, 30 (1S96). 

be placed in positions of abduction, adduction, and 
flexion, the degrees of which are indicated on a grad- 
uated scale. But, on account of the rigidity of their 
spines, they cannot show the factitious or " appar- 
ent " deformities caused by fixation of the hip in cer- 
tain positions. This is well done, however, by the 
pasteboard silhouettes seen in Figs. 99, 100, and 101. 
The facile motions of the vertebrae of these shapes 



1 64 



GRO WTH AND DEFORMITY. 



enable them to confirm the mechanics of Mr. 
Marsh's drawings. Their movable joints are lightly 
pressed shoe eyelets, two of which are posited on the 
background by screws at H in the profile and V in 



" 




Fig. 98.— Abduction, 27. 5 (1896). 



the full figure. Motion at V in the full figure allows 
the pelvis to tilt laterally, producing apparent length- 
ening or apparent shortening, while motion at V, V 
in the profile enables the pelvis to tilt antero-pos- 
teriorly for the production of lordosis. The thorax 
in the profile is backed with sheet brass, to allay fric- 
tion between guide screws. The clip is a common 



RESULTS OF HIP DISEASE. 



165 



scarf retainer. The pieces before assembling are 
seen in Fig. 102. 

To Show Production of Apparent Shortening by 
Adduction.— -In Fig. 99, V in the full figure is the 
point of motion which answers to vertebral mobility 
and allows the pelvis to tilt laterally. The clip ap- 
plied at A abolishes this motion. The limb may 
then be adducted, as in Fig. 100, by virtue of motion 
at H, which represents the position of the hip-joint. 
The clip may then be moved from A, where it pre- 
vents vertebral motion, to B, where it abolishes 




Fig. 99. — Symmetrical Positions (1896). 

motion in the hip. Ankylosis in the position of ad- 
duction is thus imitated. If, now, the limb is moved 
into parallelism with its fellow and the axis of the 
trunk, as in Fig. 101, the pelvis tilts and apparent 



i66 



GROWTH AND DEFORMITY. 



shortening is the result. In a similar way the sil- 
houette may be made to show how abduction pro- 
duces apparent lengthening. 

To Show the Production of Lordosis by Flexion. 
— Turning the page ninety degrees so as to show a 
supine profile, the letters V and V in Fig. 99 rep- 
resent the points of motion which answer to vertebral 
mobility and allow the pelvis to tilt antero-posterior- 




Fig. 100. — Adduction, 20 . Flexion, 30 . 

ly. The clip applied at A abolishes this motion. 
The limb may then be flexed, as in Fig. ioo, by vir- 
tue of motion at H, which represents the position of 
the hip-joint. The clip may then be moved from A, 
where it prevents vertebral motion, to B, where it 
abolishes motion in the hip. Ankylosis in the flexed 
position is thus imitated. If, now, the limb is 



RESULTS OF HIP DISEASE. 



67 




FlG. 101. — Apparent Shortening. Lou! - 5 

brought down to the table, as in Fig. 101, the pelvis 
tilts antero-posteriorly and lordosis is the result. It 
is interesting to note, by observing the relation of 




Fig. 102. — Parts of Fig. 99 Before Assembling. 



168 GROWTH AND DEFORMITY. 

the dotted lines to the figures, that height is de- 
creased by flexion while it is decreased or increased 
by adduction, according as the patient stands on the 
affected or on the well foot. 

To Measure Flexion. — While the patient lies in 
the supine position the limb may be raised and low- 
ered repeatedly until a point is found at which the 
lumbar spinous processes press on the table. One 
arm of the goniometer, two forms of which are 
shown in Figs. 98 and 100, may then be held horizon- 
tally, while the other is made parallel with the axis of 
the limb. The degrees of flexion are then seen on 
the scale. 

To Measure Adduction and Abduction. — When 
the point is ascertained at which the anterior supe- 
rior spinous processes are at right angles with the 
axis of the trunk, one arm of the goniometer may be 
held parallel with the line of the iliac spines. For 
convenience, if the narrow table is against the wall of 
the room, the arm of the instrument may be directed 
point blank at the wall. It will then be parallel with 
the iliac spines. The other arm may then be made 
parallel with the limb as nearly as may be. To avoid 
errors which might be caused by the presence of a 
knock-knee or a bow-leg a line from the middle of 
Poupart's ligament to the middle of the heel may be 
called the axis of the limb. Degrees of adduction or 
abduction may then be read on the scale. The arc 



RESULTS OF HIP DISEASE. 169 

of motion may also be conveniently noted and meas- 
ured. Absolute accuracy may not be expected to 
follow the application of these methods, but the re- 
sults will be better than those obtained by the use of 
the eye alone, especially after the observer has gained 
facility and accuracy by repeated use of the measur- 
ing instrument. 

Practical Shortening in the erect position may be 
estimated by placing the hands on the iliac crests 
and observing whether one is elevated above the 
floor more than the other. In the supine position, 
especial accuracy may be sought by using a pencil, 
or ink, on the iliac spine, the middle of the patella, 
and the summit of the inner malleolus before apply- 
ing a measuring tape. The relation of the great tro- 
chanter to the line connecting the iliac spine and the 
ischiatic tuberosity will reveal the shortening due to 
changes in the acetabulum and in the femoral head, 
and in the length and direction of the neck of the 
femur. In taking the position of the trochanter a 
comparison of the two sides is necessary to obtain a 
useful result. 



CHAPTER VIII, 

CAUSES AND PREVENTION OF THE DEFORMITY 
OF HIP DISEASE. 

FACTITIOUS SHORTENING. 

In advanced hip disease the limb is unavoidably 
shortened by loss of bony tissue, and to this cause 
may be added disproportionate development, from 
overuse of one limb and disuse of the other at the 
time of growth. Bilt this real or structural shorten- 
ing is not the chief factor of the lameness. The de- 
formity thus produced is not strikingly obvious. A 
new element, however, is introduced when the limb 
is fixed, by either muscular contraction or ankylosis, 
in a position which is at variance with the ordinary 
symmetry of the figure. The deformity most com- 
monly found in hip disease is a combination of flex- 
ion and adduction. But even when the limb is fixed 
in a flexed and adducted position, deformity is not 
apparent when the patient is resting; indeed, such 
a position is not in itself a deformity. This attitude 
may be taken, and is often taken, by the normal 
body. But when a limb thus situated, and fixed 

by disease, is brought into parallelism with its fellow 

170 



DEFORMITY OF H/P DISEASE. 171 

and the axis of the trunk, the absence of motion from 
the joint twists the pelvis in such a manner that fac- 
titious or apparent shortening, lateral curvature, and 
lordosis come into view and combine to produce 
the typical deformity of hip disease. This peculiar 
movement overshadows the effect of structural 
shortening and makes the hip-limp, in which one 
side is suddenly distorted at each step. In the 
characteristic lameness of hip disease, at the critical 
moment when the limb comes to a vertical position 
to receive the weight of the advancing body, the pel- 
vis rocks forward and laterally with a rude shock. 
But if the limb is fixed in a good position the pelvis 
is level when the patient stands; and when he walks 
it rocks antero-posteriorly on the lumbar joints in a 
moderate arc with resulting easy locomotion. The 
bad position is assumed early in the disease, and ar- 
rest of motion or fixation in this bad position is in- 
itiated by reflex contraction and maintained through 
and after convalescence by fibrous ankylosis. 

The Neuro-muscular Element. — Reflex contraction 
is an early and interesting clinical feature most 
thoroughly elucidated in Dr. Shaffer's valuable mon- 
ograph on " The Neuro-muscular Element of Joint 
Disease." It did not escape the eyes of John Hunter, 
who referred to it when he wrote: " Stiffness of the 
joints depends on involuntary contraction of the 
muscles. I think this arises from sympathy, or a 



172 GROWTH AND DEFORMITY. 

consciousness of the parts being unable to answer to 
the action of the muscles, and it comes nearest to 
human reason of anything in the body." Dr. Davis 
said that the muscles were " on guard-." 

The Movable-immovable Joint. — A joint thus af- 
fected has a peculiar quality by virtue of which it is 
immovable, and at the same time movable, a con- 
dition found in some forms of paralysis in which a 
limb has been likened to a piece of lead pipe which 
firmly holds its shape and yet bends on the applica- 
tion of suitable force. This quality, useful in the 
reduction of deformity, reveals its presence in the 
ordinary events of practice. Recorded degrees of 
flexion or adduction are seen to have increased or 
decreased a few hours later without any obvious 
cause, or they are rapidly reduced by weight and 
pulley or hip splint, or by the use of Mr. Thomas' 
splint in the skilful hands of Dr. Ridlon. The limb 
readily changes its position in the successive stages 
of the disease, abduction being followed by adduc- 
tion, and moderate flexion becoming extreme in the 
third stage. Recalling these changes in a limb stif- 
fened by hip disease, it may be considered not far 
out of the way to speak of the movable-immovable 
joint. Fibrous ankylosis may be quite far advanced 
without forbidding a change for better or for worse 
in the position of a limb in response to moderate 
force applied unwittingly or by design. 



DEFORMITY OF HIP DISEASE. 173 

Ankylosis. — When ankylosis is at length thor- 
oughly confirmed but little may be done to loosen the 
cicatricial tissues and contractured ligaments. The 
acute stage has long ago passed in which ankylosis 
might have been averted or lessened by mitigating 
inflammation. But it would seem that in the course 
of treatment something might be done to bring the 
limb into a good position when the joint is semi- 
tractable, and to maintain the favorable position 
until it shall have become confirmed by ankylosis. 
The ease with which the position of the limb changes 
to suit the convenience and comfort of the patient 
encourages confidence in the method to be proposed 
for the reduction of the usual deformity. 

Method of Averting Deformity.— Many suggestions 
have been made in explanation of the bad position 
assumed by the faulty limb. It has been thought 
to be due to effusion so abundant that the limb 
takes the position which accommodates the excess 
of fluid, to migration of the acetabulum and conse- 
quent change in the lodgment of the head, to spasm 
of the abductor muscles followed by their paralysis, 
giving advantage to the action of the adductors, to 
atrophy and attrition of the head, or to a painful 
spot or area on the .head, which had to be revolved 
from the depth of the acetabulum where it would 
have received too much pressure from contracting 
muscles. In some cases and stages these conjee- 



174 GROWTH AND DEFORMITY. 

tures may answer. They take into account the con- 
dition of the joint. But the morbid anatomy of 
the articulation has probably, after all, very little to 
do directly with the position of the limb, which is 
more likely to be controlled by the relation which the 
limb bears to the rest of the body. A simple and 
competent explanation is found in the statement that 
the limb obeys an unconscious demand for a position 
which meets the requirements of the patient's com- 
fort and convenience. By adduction and flexion the 
limb is bestowed quietly and comfortably when the 
patient lies down ; and when he stands the foot is 
withheld from fdrcible contact with the ground. 
But if these comfortable and convenient conditions 
were to be secured in some other way, if the joint 
were comfortably restrained from painful movements 
by a splint when he lies down, and if the apparatus 
were to hold the limb above the risk of injury when he 
walks, the necessity of adduction and flexion would 
be absent and the limb would reach for the ground 
and resume its normal relation to the rest of the 
body. The removal of the cause would be followed 
by a removal of the effect. 

Difficulty of Direct Mechanical Reduction. — Indi- 
rect removal of deformity in the way proposed would 
obviate the necessity of resorting to direct mechani- 
cal correction. It is noteworthy that an extreme 
deformity is more easily reducible by direct me- 



DEFORMITY OF HIP DISEASE. 175 

chanical force than a moderate one. A metallic rod, 
bent as in Fig. 103, may be readily straightened 
somewhat by manual traction and countertraction, as 
in Fig. 104, and still further by the same forces me- 




Fig. 103. Fig. 104. 

Figs. 103, 104. — Straightening a Crooked Rod by the Application of Trac- 
tion and Countertraction. 

chanically applied, as in Fig. 105. If it is true that 
extreme deformity is less commonly seen than for- 
merly, it is probably because fewer patients fail to 
receive traction in the third stage. It is evident, 
however, that the straighter the rod becomes the 
harder it is to make further straightening by traction. 
It is questionable whether traction can produce 
absolute straightness. It certainly cannot over- 




Fig. 105. — Mechanical Application of Traction and Countertraction (1895). 

straighten the rod. But if traction and countertrac- 
tion are replaced by the leverage of pressure and 
counterpressure, as in Fig. 106, the rod may be more 
than straightened without much trouble. Such an 



176 GROWTH AND DEFORMITY. 

application is signally useful at the knee, represented 
in Fig. 1 06, where the leverage above and below is 
ample. But at the hip, which is represented in Fig. 
107, leverage above the joint is practically absent and 
direct mechanical reduction is therefore almost out 
of the question. Control of the position of the limb 
is thus seen to be beset with difficulties. Even if the 



1 



T 




Fig. 106. — Rod Representing Knee Fig. 107. — Rod Representing Hip 
Joint Easily Straightened. Joint Straightened with Difficulty. 

Figs. 106, 107. — Straightening by the Application of Pressure and 
Counterpressure. 

deformity were reduced mechanically, or corrected 
by osteotomy, it is probable that the demands of 
comfort and convenience, when the patient returned 
from recumbency to the use of his feet, would in- 
cline him unconsciously to seek comfort and con- 
venience by reinstating adduction and flexion. The 
effect would again follow the cause. 

The Effect of a Return to Normal Rhythm. — The 
patient unconsciously assumes deformity in order 
to avoid contact with the ground, which he touches 
with the affected foot for a moment, withdrawing it 
promptly as if to move it out of the way of the well 



DEFORMITY OF HIP DISEASE. 177 

limb, which hastens to do the work of progression. 
The two feet share equally in the mischief. The 
affected one is in a hurry to leave the ground, and 
the well one is in undue haste to strike the ground. 
If a patient walking in this pernicious way is 
equipped with something that holds him above the 
reach of pain and allows equal use of both sides, he 
may also unconsciously moderate the haste of the 
well foot and allow the foot of the affected side to 
seek the ground promptly and do its share of the work. 
From the beginning of his trouble the patient has 
favored the faulty limb and thus gained the habit of 
spoiling the natural rhythm of walking, in which the 
feet mark equal time. He limps in order to make 
the well foot remain on the ground longer than the 
other one. If an applied apparatus makes this un- 
necessary, the feet will be free to move in equal time 
and the limb to resume a normal position. 

The argument for this method of reducing the de- 
formity of hip disease may be concisely stated in 
these words. The patient unconsciously assumes 
a bad position in order to secure fixation and to es- 
cape painful contact with the ground. At the same 
time the well limb usurps more than its share of work 
and thus introduces false rhythm in the act of walk- 
ing. If a splint secures fixation and protection the 
bad position becomes unnecessary, and if the patient 

voluntarily substitutes normal for abnormal rhythm 
12 



178 GROWTH AND DEFORMITY. 

the affected limb seeks the ground to do its share of 
work and the bad position is reduced. 

The suggestion of this mode of removing deform- 
ity had its origin in the observation that certain pa- 
tients recovered in good form, who for some reason 
or other had tried to suppress or conceal lameness 
while wearing a splint. They seemed to have dis- 
covered for themselves that the way to avoid the 
appearance of lameness was to make the two sides of 
the body move alike. A pretty girl, naturally vain, 
strove constantly to appear well and wore the splint 
with but little defect in her gait. She recovered 
with no adduction and only ten degrees of flexion, al- 
though the shortening from loss of bone measured 
two inches. The following is another instance : 

Case XIV. — Unconscious Correction of the De- 
formity of Hip Disease. — A girl, five years old, when 
first seen in May, 1880, had suffered from disease of 
the left hip for eighteen months. A weight and pul- 
ley and a diet consisting of small portions of mutton 
broth were replaced by a splint and by a liberal menu. 
Through-and-through drainage had been established 
and exsection had been advised. In due time lo- 
comotion was resumed and scars took the place of 
sinuses from which pieces of bone had been expelled. 
She was the only daughter and constant companion 
of a careful mother. The fact of disability was not 
referred to in conversation and its appearance was 



DEFORMITY OF HIP DISEASE. 179 

excluded so far as possible. The child made good 
use of the affected limb, protected by the splint, and 
walked without a very noticeable defect in her gait. 
Health and strength were entirely restored and re- 
covery was marked by two inches of bony shorten- 
ing, only three degrees of adduction and practically 
no flexion, lameness being evident only when she 
was in haste or moved carelessly. The good position 
of the limb and her general health were maintained 
until her fatal illness, which is recorded in Case 
XIX. (pp. 215, 216). 

On the other hand, a boy live years old, whose 
mother was employed away from home all day, 
shared the sports of three healthy brothers and re- 
covered under the same treatment and from a milder 
form of the disease with twenty degrees of adduction 
and fifty degrees of flexion, a result which was later 
made the subject of successful osteotomy. The ab- 
scess in this case is described on page 132. 

Another child, in a large family, where circum- 
stances precluded ordinary parental care, recovered 
without an abscess and with forty degrees of adduc- 
tion. Her deformity was completely and easily re- 
duced in a hospital ward by recumbency and a 
weight and pulley, but it promptly returned when 
the child went home and resumed the hip splint with 
which, disregarding advice and instruction, she main- 
tained an asymmetrical gait. 



180 GROWTH AND DEFORMITY. 

It has not been found easy to reform the perni- 
cious gait acquired by a lame child. The bad habit 
begins early in the disease. It is the first sign of 
trouble. Groups of muscles fall at once into disuse, 
and other groups are unduly developed. In this 
state of affairs the readjustments of muscular ac- 
tivity and development called for by a return to 
normal rhythm, are not made without some trouble. 
Such an undertaking will meet with especial diffi- 
culty in the case of an adult. In the tractable years 
of early life, however, when the muscles and joints 
are increasing in size with the growth of the whole 
body, and when new methods of walking or march- 
ing are welcomed as diversions, such changes are 
more readily made and should not be left to chance, 
but intelligently directed so that they may assist 
and not impede successful locomotion in adult life. 
What is more abhorrent than the thought that the 
daily wonder of juvenile growth is adding .to the 
misfortune and helplessness of the crippled condi- 
tion ? 

STRUCTURAL SHORTENING. 

Real shortening is simple in its causes when com- 
pared with the shortening produced by fixation in a 
bad position. It follows acute epiphysitis of the hip 
with the result seen in Figs. 108 and 109. It is seen 
in single congenital dislocation of the hip. In- 



DEFORMITY OF HIP DISEASE. 181 

stances are often found after infantile paralysis from 
disuse of one side and overuse of the other, and it is 
seen more rarely in those cases of unilateral atrophy 
or congenital asymmetry which are marked enough 





Fig. 108. Fig. 109. 

Figs. 108, 109. — Shortening Five Years After Acute Epiphysitis of Left 
Hip. Girl nine years old. Spinal curve reduced by factitious length- 
ening (1877). 

to cause disproportion in the length of the lower 
limbs. Fracture of the femur of the longer limb and 
union with shortening has been proposed, but not 
often practised, as a method of obviating the effect 
of structural shortening. 



1 82 GROWTH AND DEFORMITY. 

Local Hyperemia and Anaemia. — Interesting sug- 
gestions are derived from an observation, reported 
by M. Broca, of the effect of local hyperaemia on the 
rate of growth. In a case of aneursymal varix follow- 
ing wounding of the crural artery and vein in a child 
it was found, fourteen years later, that limping, 
which had been supposed to be due to weakness of 
the limb, was the result of lengthening of more than 
an inch. The foot also was lengthened. Such cases 
are said to be attended by preternatural growth of 
hair on the limb. Hyperaemia, induced by constric- 
tion applied to check the venous flow, is easily prac- 
tised and has produced good results in the cases of 
joint disease reported by Dr. Freiberg. This, com- 
bined with anaemia, induced by rolled or laced ban- 
dages applied to the longer limb, might be expected 
to promote symmetry in- cases of structural shorten- 
ing. At the same time the labor of walking might 
be redistributed by an ischiatic crutch and a high 
sole in order to retard the growth of the longer and 
hasten that of the shorter limb. It is stated by 
Helferich that physiological as well as pathological 
growth may be increased by hyperaemia, and that a 
young growing bone may, under this influence, be- 
come thicker and longer. Reinforced by the activity 
which possesses the development of tissue at the time 
of growth, such methods give room for a reasonable 
expectation of success. 



DEFORMITY OF HIP DISEASE. 



*3 



To Circumvent Actual Shortening. — The first prac- 
tical resort is usually to a high-soled shoe for the 
short limb and the removal of part of the sole from 
the shoe of the long limb. 
In suitable cases the well- 
known Extension Shoe is 
useful. A durable form 
of this shoe, weighing 
two pounds and four 
ounces, is seen in Fig. 
no. In many cases if 
the shortening is not ex- 
treme the desired effect 
may be found, and with 
less obvious deformity 
and inconvenience, by 
discarding the high sole 
altogether, withholding 
the heel from the ground 
and walking tiptoe on the 
affected side, as is done 
by the patient seen in 
Figs. 81 and 82 (p. 154). 

The Equine Position 
of the Foot is enforced in 
an extension shoe. It is cheerfully adopted without a 
murmur of discontent by those who wear fashionable 
high heels, by which the stature is increased without 




FlG. no. — Extension Shoe of 
Wood and Steel. Length of limb 
varied by adjustment of straps 
and buckles (1S96). 



1 84 GROWTH AND DEFORMITY. 

a total loss of grace. The foot takes this position in 
the pirouette of the ballet, and in statuary which ex- 
presses the lightness and activity of the human fig- 
ure. As the toe alone touches the ground when a 
hip splint is worn, patients easily continue in the 
habit of walking in this way when they are advised 
to do so and to avoid a high sole ; and when recov- 
ery follows a very prolonged period of treatment, 
a structurally shortened tendo Achillis decidedly 
favors an equine position of the foot. Since stand- 
ing on tiptoe' increases the stature, it is certainly rea- 
sonable to lengthen a limb which is unfortunately 
short by standing on the toe of that foot. This will 
facilitate efforts to practise and acquire a symmetri- 
cal or normally rhythmical gait. 

LIMPING, OR LAMENESS. 

It is well to bear in mind that the lameness which 
attends a short limb depends not so much on visible 
want of symmetry in the lower extremities as on a 
faulty carriage of the body. If the two sides of the 
body in general move alike, or symmetrically, the 
details of measurement are unimportant. Lameness 
in general may be defined as asymmetrical locomo- 
tion. It is said that horse dealers will on occasion 
conceal the defect in an animal lame in the left fore- 
foot, for instance, by a cruel device which makes the 



LIMPING, OR LAMENESS. 185 

horse lame in the right foot also. A wedge is placed 
between the shoe and the well hoof, causing trouble 
on that side which duplicates the disability and hides 
lameness by balancing defective action. Infantile 
paralysis often vitiates the gait by introducing tardy 
action on one side, which may be duplicated by an 
effort on the part of the patient to make the well 
side imitate the affected one. Lameness then gives 
way to the rolling gait of a jolly tar ashore. A well 
person can walk lame at will by giving more time to 
one foot than to the other, a matter of easy demon- 
stration if the experimenter will walk across the 
room, taking pains to let one foot linger on the floor at 

each step, marking time as follows : 1 ..2 1 ..2 1 ..2. 

Conversely, one who is. lame may lessen the ap- 
pearance of being so by observing the natural 
1. .2.. 1. .2.. 1. .2.. 1. .2 rhythm of locomotion which is 
more effective in banishing a limp than the equine 
foot or extension shoe. 

The Rhythm of Human Locomotion has perhaps 
not received the attention to which it is entitled. 
When normal it is absolutely simple in comparison 
with the varieties seen in quadrupedal action. The 
time is of course equally divided between the two 
feet. When rhythm is abnormal, the giving of more 
time to one foot than to the other introduces lame- 
ness. True time may be expressed as follows : 
1. .2.. 1. .2.. 1. .2.. 1.. 2.. 1. .2.. 1. .2.. 1. .2, 



1 86 GROWTH AND DEFORMITY. 

and false time thus : 

I. .2 I. .2 1. .2 1. .2 1. .2 1. .2. 

In a child who shows a limp, and no other sign, it is 
not easy to say off-hand which is the affected limb. 
Attention will show that the sound limb strikes a 
quicker blow than the other, and remains longer on 
the ground. 

Symmetrical Walking. — Aside from the proposed 
method of correcting adduction and flexion in pa- 
tients who are under treatment, it remains that the 
habit of symmetrical walking by those who are lame 
from hip disease, or from any other cause, is practi- 
cable and desirable. A good degree of excellence 
in walking is attainable by those who are badly dis- 
abled. Instances of this have already been cited, 
and similar cases have doubtless been observed by 
others. That they are not more common is prob- 
ably because sufficient attention has not been given 
to this subject in practice. More time accorded to 
the prevention of lameness by simple and common- 
place methods would relieve many cripples of a large 
part of their misfortune. It is difficult to set limits 
in suitable cases to the success of efforts of this kind 
in the formative stages of childhood and adolescence. 
The development of the necessary muscular fibres 
by daily systematic use and the natural growth of 
the affected and related parts combine to bring about 
a result which cannot well fail to be permanent. In 



LIMPING, OR LAMENESS. 187 

a child thus brought up all the muscles and joints 
and co-ordinate acts of the body will conform as 
growth progresses with increasing facility and accu- 
racy with the demands of improved locomotion. 

The Acquirement of Correct Rhythm. — Some chil- 
dren will fall into the new order of such a curriculum 
with readiness and pleasure, while others are likely to 
be wilful and impatient of additional restraints and 
regulations. One or two efforts to walk in good 
time, or an occasional exercise, will be without effect. 
Instruction should include the repetition of a syste- 
matic drill, a procedure orthopaedic in view of the 
etymology of the word, an educational process like 
the training of a military recruit. From force of 
habit the learner should mark correct rhythm in 
walking, as a soldier carries out the manual of arms 
under fire, as a matter of habit or second nature. 
Time should be counted in the promenade, as in a 
music lesson, line upon line and precept upon pre- 
cept. In these efforts to induce correct action atten- 
tion should be paid to both of the feet, the affected 
one being taught to remain longer on the ground 
and the well one not to strike the ground too soon. 
Dancing exercises will not be out of place. Per- 
sonal vanity may be stimulated, and an ambition to 
appear well. A wall mirror will help an observant 
child to improve his gait. An impressive deport- 
ment should especially be encouraged in those who 



188 GROWTH AND DEFORMITY. 

are disabled. If naturally healthy children are ben- 
efited by military drill and instruction in danc- 
ing, it is still more important that the afflicted should 
have these educational advantages. Treatment car- 
ried out in this way may involve trouble, and the 
time of skilled and patient attendants will demand 
outlay. When convenient, instruction might be 
given and exercises might be repeated in classes, 
with music and competitive drills by mimic military 
companies. The probable result would be seen in 
adults with but moderate lameness in place of num- 
bers whose obvious defects entail a lasting disability. 



CHAPTER IX 
POTT'S DISEASE OF THE SPINE. 

The presence of tuberculosis is discovered with 
more difficulty in the spinal column than in any 
other part of the skeleton. The bodies of the verte- 
brae lie behind barriers of bone, muscle, and viscera, 
as far removed from the surface as possible. For 
this reason the discovery of disease here comes as an 
unpleasant surprise. Disintegration will have made 
great progress before the contour of the back shows 
even so slight a break as that seen in Fig. 1 1 1, which 
indicates the loss of considerable substance from one 
or two of the vertebrae. This angular projection is 
the first objective warning of Pott's disease, although 
earlier and doubtful signs are a lateral deviation and 
a timid or repressed gait. 

When the articulation of a long bone is diseased 
the effect of deranged motion is projected to a dis- 
tance, reaching the circumference of a circle of 
which the long bone is the radius; but when a short 
and irregular bone is affected, the radius of disturb- 
ance is decidedly circumscribed. Lameness invites 
attention to disease in the lower extremities long 

before loss of bony tissue produces real shortening 

189 



igo GROWTH AND DEFORMITY. 

and deformity. But when the spine is diseased loco- 
motion is but little affected and limitation of motion 
is not readily perceived. The result is that diagnosis 
is usually necessarily postponed until excavation of 
the vertebral bodies and loss of large portions of 
bone produce a positive and unmistakable deformity. 



Fig. hi. — Normal Curve Broken by Caries at the Eleventh Dorsal. Roy 
four years old. Duration of disease four months. (Bellevue Hospital, 
1877.) 

It is disconcerting to reflect that this malign process 
may be undermining the bones of the spine, the 
foundation of the edifice, so to speak, for so long a 
time undetected even under careful observation and 
acute suspicion. If such foci of disease are resolv- 
able, when favorably situated in those parts of the 
skeleton which are exempt from weight-bearing, then 
arrest of this function of the spine should without 



DIAGNOSIS OF POTTS DISEASE. 191 

delay follow even slight suspicion of trouble. Ready 
acceptance may well be given to published reports of 
instances of early and tentative treatment followed 
by retention of normal shape and ability. In youth, 
when the resistive and reparative powers share in the 
vigor which the whole body exhibits in its rapid 
growth and development, it is desirable to encourage 
the tissues to wall off such an infection, and reason- 
able to expect good results from timely treatment. 

Pott's Disease in the Aged. — Although pre-emi- 
nently a disease of childhood, it may not be forgot- 
ten that Pott's disease occurs at all ages, and is not 
easily detected in the later years of life, when its 
presence may be obscured by spinal stiffness and 
deformity so commonly observed as the results of 
rheumatoid and other affections which visit the ver- 
tebral column in old age. The gait and deportment 
of the patient, so important in the early diagnosis of 
this disease in children, may be overlooked when the 
patient is in advanced life, but none of the other 
usual signs and symptoms may be safely neglected. 

DIAGNOSIS. 

Pain in the stomach is the most important symp- 
tom. Two lines which should find a place in the vade 
mecum are: The pain of spine disease is in the stom- 
ach and the pain of hip disease is in the knee. A pre- 



192 GROWTH AND DEFORMITY. 

scription for recurring colic should be preceded, or 
presently followed, by a careful inquisition concerning 
the health of the vertebral column. Inspection may 
reveal a projection in the median line, which may be 
located by counting from the seventh cervical ver- 
tebra, or from the fifth lumbar, which lies between 
the posterior superior spinous processes of the ilia, 
or one enumeration may be verified by the other. 
Dr. Whitman states that the fourth lumbar vertebra, 
on a line with the highest point of the crest of the 
ilium, is the most constant landmark from which to 
count, the umbilicus being near the same plane. 
The rounded back of rickets, or that of spastic con- 
traction, should not be mistaken. In the lower dorsal 
region, from the sixth to the ninth vertebra, it is also 
well to avoid a peculiar source of error. Here the 
spinous processes incline downward, overlapping like 
the tiles on a roof ; and when a thin patient bends for- 
ward they approach the horizontal and make a pro- 
jection leading to unnecessary apprehension, which 
may be avoided by noticing whether the projection 
is angular or not. Lower down the summits of the 
spinous processes in a thin person may be occupied 
by distinct calluses, caused by the pressure of the 
clothing ; but these move with the skin. 

The expression Angular Curvature has been criti- 
cised on the ground that an angle and a curve are 
essentially different. In practice, however, the term 



DIAGNOSIS OF POTTS DISEASE. 



93 



is convenient, the normal long curve being broken 
into two short curves, meeting end to end in an 
angle. This point may not project far, but if it 
marks the union of two curves, in even a slight de- 
gree, as in Fig. in, it means that destruction of 
bone has occurred. An angu- 
lar curvature is usually an ab- 
solute demonstration of the 
presence of Pott's disease. 

Equilibrium Preserved by Lor- 
dosis. — When a considerable 
angle is present lordosis 
promptly restores equilibrium. 
In Dr. Homer Gibney's patient 
(Fig. 112), the deformity throw:, 
the upper part of the body for- 
ward, compromising equilibri- 
um, which is safeguarded by a 
compensating c u r v e below. 
The same is seen at A and B 

in Fig. II3. Lordosis, SCOH- Fig. 112.— Equilibrium Re- 

osis, and kyphosis denote the 
three directions of spinal curv- 
ature. Lordosis is transient. 
Except in opisthotonos it does not have the rigidity 
common to the other forms of deviation, and it dis- 
appears with recumbency. It is an adventitious or 

incidental curve, seen in double congenital disloca- 
13 




stored by Lordosis. Age 
seven years. Ninth dor- 
sal. Duration two years. 
(H. Gibney, 1900.) 



194 



GROWTH AND DEFORMITY. 



tion of the hip, and also when a weight is carried 
in front, as in gestation. It accompanies the flexion 
of hip disease, or that produced by a shortened psoas 




□ 



) 

B 



e P 



c 



D 



Fig. 113. — Equilibrium Restored by Lordosis and Horizontal Vision by 
Extension of the Head (1901) . 

muscle in Pott's disease. It is seen in the saddle- 
back of pseudo-hypertrophic muscular paralysis. 
Enforced lordosis at the lower part of the spine 
would probably counteract the effects of puerperal 
dislocation of the pelvic bones, as was pointed out 
by Dr. Goldthwait at a recent session of the Amer- 
ican Orthopaedic Association. 

Diagnosis in the Cervical Region. — It is often diffi- 
cult to distinguish between caries in the middle and 
upper cervical region and rheumatic stiffness of the 
posterior muscles of the neck. Disturbance of the 
head is very positively resented in both affections, 
and even when the wry-neck is the result of caries 
an angle is not easily perceived, the cervical proc- 



DIAGNOSIS OF POTTS DISEASE. 



195 



esses being small, separated by narrow intervals and 
hidden by the muscular masses of the superior fibres 
of the trapezius. In some cases a point may be 
gained by looking for displacement forward of the 
axis of the head, which is produced by the action 
shown at C and D in Fig. 113. At C the head is 
inclined forward by kyphosis in the cervical region, 





Fig. 114. 



115. 



Figs. 114, 115. — Cervical Disease. Forward displacement of axis of head. 
Age fifty years. Duration five years Horizontal vision restored by 
extension of head. (New York Hospital.) 



when the necessity of maintaining horizontal vision 
induces extension of the head and produces what 
may be called lordosis above the seat of disease. 
The result is a forward displacement of the axis of 



196 GROWTH AND DEFORMITY. 

the head, seen at D, and also seen in Figs. 114 and 
115. This patient, fifty years of age, presented the 
widening and prominence of the upper and back part 
of the neck, which is admirably shown by a cut in 
Dr. Young's treatise. She had been entirely dis- 
abled for many months, in which her head had been 
flexed and tilted to the left. Relief had been sought 
by manual support of the head and by the careful 
arrangement of many pillows at night. The lower 
part of the spine and all of the other joints were nor- 
mally flexible. When observed in 1 901, and again in 
1904, painless crepitus was produced at will by rota- 
tion to the right with the head flexed and supported 
by the left hand. It was always the same, being 
composed of three or four closely connected sounds. 
Occurring sometimes unexpectedly it was alarming 
in its distinctness. It was thought to be analogous 
to the crepitus not uncommon after disease in other 
joints, and could hardly have occurred after Pott's 
disease except in the cervical region, where the ver- 
tebrae have considerable mobility. 

To make a diagnosis before the appearance of de- 
formity, several things may be borne in mind. The 
child avoids stamping with his heels and puts more 
weight on his toes than is customary; or he walks 
as one stepping on a surface liable to break; or the 
line made by his head as he moves across the room 
is straight and not the undulating line traced by the 



DIAGNOSIS OF POTTS DISEASE. 197 

rise and fall of the figure in the buoyant gait which 
belongs to childhood. The deportment is then to 
be considered. He will play quietly by himself; or, 
easily tired, lean across his mother's lap ; or, if the 
disease is at a high level he may support his head 
manually when sitting and even when walking. His 
forehead may rest on the edge of a chair, his hands 
being busy with toys on the floor. He is disturbed 
by the jar of a carriage or street car. The progress 
of a rough game may be interrupted by a seizure of 
gastralgia, laughter ending in tears. A common 
sign is a frequent or habitual grunt with expiration. 
By following these lines of observation a positive 
diagnosis may happily be made before the unmistak- 
able angle appears. In diagnosis but little attention 
may be paid to the general condition. Many cases 
are encountered in which the health is good in every 
stage, as shown by normal appetite, good digestion, 
and wholesome facial expression and color. While 
these signs of general well-being are persistent the 
insidious foe may be in quiet pursuit. 

Unexpected Clinical Features. — In two points thus 
far the unexpected has claimed attention. The pain 
is in the stomach and not in the back, and the health 
seldom shows a reaction. Another surprising clini- 
cal feature is seen in the fact that, although the back 
is virtually broken in Pott's disease, the local disabil- 
ity which usually attends fractures is very rarely ob- 



198 GROWTH AND DEFORMITY 

served. So true is this that in the presence of spinal 
pain and disability the prompt conclusion is that the 
affection is not Pott's disease. When these alarm- 
ing symptoms, pain and disability, are combined 
with a frank onset, it is necessary to consider the 
possibility of cancerous disease involving the verte- 
brae. 

Case XV. — Malignant Disease of Vertebrcz. — In 

1884 a boy, four years and eight months old, had 
been noticed walking and stooping carefully and 
stiffly. The contour of the spine was nearly or quite 
normal. Pott's disease was recorded by independent 
observers and preparations were made for mechani- 
cal support. Six days after the first examination 
paraplegia occurred, and two days later a catheter 
was required, withdrawing pus and blood with the 
urine. The bowels were regular and pain in the back 
was urgent. The abdomen was tympanitic. There 
was no oedema of the limbs. The temperature was 
101 F. Occasional slight convulsions were noted. 
Ten days later death occurred after partial disap- 
pearance of the paraplegia. The autopsy revealed 
no caries, but many tumors were found attached to 
the dorsal vertebrae and the ribs. The largest was 
about two and a half inches in diameter. The neo- 
plasm had entered the vertebral' foramina. 

Case XVI. — Malignant Disease of Vertebrce. — In 

1885 a man, thirty-five years of age, had suffered 



DIAGNOSIS OF POTT'S DISEASE. 199 

much for several months with pain in the thighs from 
supposed renal calculus. There was great loss of 
flesh. Painful disability was so extreme that he 
could with difficulty lie down or rise from a couch. 
The spinal curves being normal, Pott's disease was 
excluded, a former diagnosis being reversed. When 
an autopsy was made five months later, malignant 
growths were found in the lungs and on the dia- 
phragm and vertebral column. 

Case XVII. — Malignant Disease of Vertebra. — 
In 1890 a brace was applied to the spine of a man 
who was paraplegic from supposed Pott's disease, 
following a strain when helping to lift a piano. The 
eighth dorsal vertebra showed a slight angular promi- 
nence. After ten weeks, in which the history in- 
cluded faecal and urinary incontinence, an explo- 
ratory opening made in the vertebral canal, with the 
hope of relieving the paraplegia, exposed an unsus- 
pected sarcoma. The patient lived a few days, and 
inspection was not carried further. The chief points 
of differential diagnosis, as formulated by Dr. Myers, 
are: Deformity present in Pott's disease and absent 
in malignant disease; and local pain and disability, 
absent in Pott's and present in malignant disease. 

Deplorable Effects in the Dorsal Region. — The joints 
of the spine are, from their position near the centre 
of gravity and motion, peculiarly exposed to me- 
chanical disturbance. In this respect their environ- 



200 GRO WTH AND DEFORMITY. 

ment is the counterpart of that of the hip-joint, which 
was so, forcibly described by Mr. Charles Bell (see pp. 
98, 101). For this reason among others caries of the 
vertebrae is a most serious affection. Very much, 
however, depends on the region involved. In the 
dorsal region, excepting malignant trouble, it is prob- 
ably the most serious affection that may visit the 
growing skeleton. Here the disease is likely, if neg- 
lected, to extend for a considerable distance along 
the spine, with liquefaction of large portions of bone 
and a portentous kyphosis, because here the column 
is at its greatest* mechanical disadvantage. The 
effect of a transverse strain diminishes as the ends 
of a column are approached. In the dorsal and lum- 
bar regions rotation adds to mobility when the spine 
bends laterally, and in the former the movements of 
respiration subject the diseased bones to habitual 
traumatism. In the cervical region the vertebrae 
have less weight to carry. In the lumbar region the 
vertebral bodies by reason of their size exhibit a firm 
relation of mutual support. This natural support is 
so strong and the effect of a lever so near the end of 
a column is so weak that mechanical support given 
to the lumbar spine is not practically a useful appli-, 
cation. For these reasons tuberculosis of the ver- 
tebrae and its effects are less to be dreaded in the 
upper and lower regions than in the dorsal region of 
the spine, where the intractableness of the affection 



TREATMENT OF POTTS DISEASE. 201 

and its serious results are but too well known. 
Here the demand for painstaking and urgent treat- 
ment is imperative. 

TREATMENT. 

Whatever the difficulties, authorities unite in the 
opinion that nil desperandum should be the rule 
when treating Pott's disease. The tuberculous proc- 
ess in this as in other parts of the skeleton may not 
be cut short by operative, or any form of positive, 
procedure. The cessation of this form of morbid 
activity may, however, be confidently predicted, and 
a suitable mechanical environment, reinforced by the 
vitality of adolescence, may be relied on to hasten 
the advent of the natural process of repair. The un- 
dermined vertebrae may be placed in their best ex- 
pectant attitude by restraining the facile movements 
of the column, by taking from it the burden of im- 
pending weight, and by averting the jar which it 
feels at every step in walking and running. 

Recumbency. — In the treatment of hip disease, 
while the patient is up, the limb is put to bed, so to 
speak, by ischiatic support, an effective method not 
applicable here. The recumbent position may there- 
fore be prescribed and continued so long as it is 
practicable with due regard to the patient's age and 
general welfare. It is clear that in this position the 



202 GROWTH AND DEFORMITY. 

spine is free from weight-bearing and concussion 
and, to a limited extent, from motion. Recumbency 
in a young patient may be enforced by the use of 
Dr. Bradford's admirable portable frame, made from 
steel tubing, and arched by Dr. Whitman at the level 
of the disease to oppose deformity. On this the 
child enjoys freedom from disturbance which might 
excite the morbid process or delay its resolution. 
The environment thus secured is eminently hos- 
pitable to the approach of repair and recovery. The 
width of the frame is from six to nine inches, the 
width of the body, not of the shoulders. The under- 
shirt is cut up the back and buttoned only behind 
the neck, the rest of the clothes, or blankets, going 
around the frame. The patients wheel themselves 
on suitable wagons in the house and are carried into 
the open air, perfectly happy and contented for a 
year or more. Dr. Napier, describing the arrange- 
ment, writes that in this way he treats children up to 
nine or ten years of age, and adds that he thinks no 
other method its equal. 

Mechanical Support. — But when the patient gains 
in weight and size, and the demands of education in 
various ways become imperative, it will be desirable 
to resort to some method not incompatible with 
walking. It is evidently not an easy undertaking to 
arrest motion in the many-jointed spine. In white 
swelling of the knee a simple retaining brace fixes 



TREATMENT OF POTT'S DISEASE. 203 

the joint with a leverage which is wanting in a simi- 
lar application made to the spine. In the hip fixa- 
tion is successfully and with advantage developed by 
traction, and this may be applied to the uppermost 
region of the spine when the patient is recumbent. 
But in the erect position traction is not conspicuous- 
ly successful as a fixative. Suspension of the head 
by the jury mast, applied to avert impending weight 
and straighten the column, is attended by an uncer- 
tain degree of fixation, theoretical rather than prac- 
tical, and not to be compared with the comfortable 
fixation which is developed by traction of the leg. It 
may therefore be inferred that fixation of the erect 
spine is to be sought only by applying a retentive 
lever designed for making pressure at the level of the 
projection and counterpressure above and below. 
An obvious effect of this application is a redistribu- 
tion of intervertebral pressure. As the column in- 
clines forward, making a salient posterior angle, there 
is a critical increase of pressure from impending 
weight on the anterior rim of the affected vertebra. 
A brace at once takes off some of this traumatism 
and puts it on the posterior and sound part of the 
bone. It is a faint imitation of the admirable me- 
chanics of the hip splint which transfers weight from 
the affected to the sound limb. Injurious pressure 
is thus mitigated and a barrier is thrown up at the 
same time against increasing deformity. 



204 GROWTH AND DEFORMITY. 

If such an apparatus, efficient in theory, proves not 
to be mechanically perfect in practice, it will still be 
found to be useful. The presence of a succession of 
jointed short bones instead of a single long bone 
above and below the diseased point introduces an 
element of inefficiency in the action of this otherwise 
admirable apparatus. The force applied to oppose 
deformity is unfortunately largely absorbed in bend- 
ing backward sound portions of the column above 
and below the point of disease. And yet a useful 
degree of fixation may be made, enough to check 
gastralgia, to promote comfortable activity on the 
part of the patient, and to secure a diminution of 
ultimate deformity. It is important and interesting 
to observe that in this way an incidental improve- 
ment is secured in the patient's figure. As the spine 
yields to pressure, lordosis is formed above and be- 
low the projection, and the trunk acquires a general 
straightening and a fulness of the chest, which mod- 
ify the typical deformity produced by this affection. 

Incidental Improvement of the Figure. — Long-con- 
tinued wearing of such a brace, even after consolida- 
tion is assured, changes the figure by lessening the 
roundness which is usually seen behind the shoulders 
and by giving prominence to the chest, which is a 
decided improvement. The torso of a young pa- 
tient may be seen to double its size with the child's 
growth. The adolescent years in such a case may 



TREATMENT OF POTT'S DISEASE. 205 

therefore well be occupied by mechanical support of 
a positively antero-posterior kind, which will give 
ever increasing benefit from its coincidence with 
the period of growth and development. Indeed, if 
effective, the brace will be so comfortable and help- 
ful that the patient will prefer to continue its use 
long after removal has been prescribed. It is only 
in the dorsal region that the brace can thus exert an 
influence on the figure. In other regions treatment 
may be discontinued when consolidation is com- 
pleted. 

Natural Reaction and Consolidation. — It is not to be 
hoped that mechanical treatment will at once induce 
consolidation. This will wait for the appearance in 
due time of natural reaction, but it is not difficult 
to believe that nature will more promptly intervene 
when distress and weakness and apprehension are 
replaced by a feeling of strength, which finds expres- 
sion in the face and attitude. If it were only pos- 
sible successfully to apply positive means for the 
arrest of the tuberculous process, the damaged ver- 
tebrae might be treated at once as if they had sus- 
tained a simple fracture. Instant provision should 
then be made for consolidation or union. Coap- 
tation of the fragments and their retention in posi- 
tion should then be sought just as they are after a 
fracture of any part of the skeleton. If tuberculous 
action were really absent it might be well even 



206 GROWTH AND DEFORMITY. 

to adopt the periodically rejuvenated proposition to 
break the angle and straighten the spine. Other- 
wise such a ruinous procedure as Forcible Correction 
should not be added to the burden of traumatism 
which the tuberculous spine carries as the centre of 
motion for the whole body. 

Details of Mechanical Support. — The steel brace has 
a feature which is invisible, and yet of the greatest 
importance in the tractable quality of the metal used. 
On this depend the efficiency of the application and 
the comfort of the patient. To secure these ends in 
full measure requires the most studious attention. 
The form of the brace before its application will be 
determined in a general way by the shape of the pa- 
tient's back, and yet almost at once the latter will be 
changed for the better by contact with the brace and 
in turn an improvement in the shape of the brace 
will be seen to be desirable almost immediately. 
Thus the patient's figure and the brace will alter- 
nately take on progressive changes by a series of 
slight but imperative modifications of the apparatus 
which require the frequent exercise of skill and in- 
genuity. The growth of the child will call for some 
of these changes; possible diminution of the angle 
will determine others. Considerations of comfort 
will lead to more or less radical alterations in the ap- 
paratus. These changes may be sought by bending 
or straightening the frame of the brace, by substitut- 



TREATMENT OF POTTS DISEASE. 207 

ing stronger parts for those that have come to be too 
weak, and by shifting the position, direction, and ten- 
sion of buckles and straps. Too much attention 
cannot be given to the ever- recurring problems which 
such a case presents. 

Rule for Regulating Pressure.— A spinal column 
yielding under the weight of the head and upper part 
of the body resembles an edifice requiring temporary 
support while necessary repairs are being made. 
But the spine can be supported only by pressure 
made on the sensitive and easily wounded skin, 
which interposes an imperative and serious limit to 
what can be done in this direction. A brace is in- 
deed an outside skeleton like those of the crusta- 
ceans referred to on page 54. A practical rule 
therefore formulates itself as follows: The apparatus 
may be considered as having reached the highest 
point of efficiency when it makes the greatest press- 
ure on the projection compatible with the integrity 
of the skin. By assiduous care and attention this 
seemingly harsh rule may be strictly observed with- 
out compromising in any degree the comfort and 
convenience of the patient. If, contrary to common 
prudence, the brace is fastened in place at once as 
tightly as it can be borne, the skin wjll immediately 
react with pain and ulceration. But if the pressure is 
lightly applied at first, and gradually and carefully 
increased from time to time, it will be found as the 



208 GROWTH AND DEFORMITY. 

weeks and months pass that the skin will have be- 
come hardened without losing its integrity or caus- 
ing discomfort, and its condition will indicate 
whether or not the patient is receiving the full bene- 
fit of mechanical treatment. It has been proposed 
to avoid the vulnerable skin and support the deca- 
dent vertebrae by wiring their processes together. 
The suggestion was ingenious, but its cleverness did 
not save it from failure through structural weakness 
of the young and recently ossified processes. If, 
through negligence, abrasion and ulceration occur, 
the urgency of the application should be relaxed, to 
be resumed later with more watchfulness and care. 
An affection so insidious in its action and so likely 
to be followed by disastrous consequences demands 
the most efficient, albeit difficult, treatment. 

The Plaster-of-Paris Jacket. — It maybe questioned 
whether a process so laborious and involving so 
many nice details is practicable, whether so much 
time can rightfully be given to these cases, so nu- 
merous in an orthopaedic clinic. The serious and dis- 
abling effects of the disease, however, cannot but 
urgently call for liberal expenditure of effort, which 
should be the more insistent because at the age of 
these patients every slight betterment represents a 
more conspicuous gain extending into adult life. 
Other methods of treatment, including forced exten- 
sion in the prone position and plastic dressings, may 



TREATMENT OF POTTS DISEASE. 209 

not be strictly governed by the rule proposed for the 
regulation of pressure. Such methods, however, are 
highly commendable. They call into play a diffused 
pressure, not very liable to wound the skin, but not 
readily adjustable in degree and direction. The in- 
troduction of the plaster-of- Paris jacket especially 
has conferred benefit on vast numbers of sufferers 
who would otherwise have been denied mechanical 
relief. In Pott's disease, as in all orthopaedic prac- 
tice, there can be no hard-and-fast rules as to the de- 
sign or material used in the apparatus. No method 
has proved to be better than all others on every occa- 
sion. Questions of detail are to be met and an- 
swered as they present themselves, and no case will 
release the physician from the necessity of studious 
and persistent readiness to meet the mechanical 
emergencies as they arise. In the upper regions of 
the spine, for instance, the head may be supported by 
a stock-like collar, or a jury mast with flexible rests 
for the chin and occiput, or a less conspicuous un- 
yielding support for the forehead or chin, or both. 
The latter may rise from a brace provided with well- 
padded curved pieces surmounting the shoulders. 
In any of these ways the weight may be partly re- 
moved from the spine to the shoulders, or hips, or 
transferred to the posterior section of the column, 

with comfort and advantage. 
14 



210 GROWTH AND DEFORMITY. 

RESULTS AND COMPLICATIONS. 

Among the results of Pott's disease is Reduction of 
Stature. Valuable tables, showing the rate of growth 
in spondylitics, have been prepared by Dr. H. L. 
Taylor, revealing the important facts that the rate 
of growth is higher for patients who are under 
strict mechanical treatment and efficient manipula- 
tion, and that a low rate calls for further support, or 
resumption of support, if it has been discontinued. 
Reduced height is caused chiefly by the shortening of 
the spinal column. It is supposed, but not yet demon- 
strated, that an important cause is retarded general 
growth from malnutrition accompanying the disease. 
The disproportion in the lengths of the trunk and 
the limbs is especially seen in patients who would 
have been tall men and women if the spine had not 
been shortened by disease. In the act of sitting the 
head and shoulders of such a patient descend until 
they are considerably below the common level, as 
seen in Fig. 116. This has led to the suggestion 
that prosthetic apparatus might be applied to lessen 
this appearance. In Fig. 117 such an apparatus is 
represented as supporting the trunk with the head 
and shoulders near the normal level. Worn under 
the clothes, it should collapse when the wearer rises, 
and come into action automatically when he sits. 
Its bearings should be on the ischiatic tuberosity and 



CO MP LIC A TIONS OF PO TT ' S DISEA SE. 2 1 1 



along the femoral shaft, the parts which commonly 
receive the corporal weight in the sitting position, as 
seen in Fig. 118. The head of a sitting figure is 
seen in Figs. 117, 118, and 119, at about its normal 
altitude, which is maintained without difficulty by a 
well man, whose weight falls on the ischium and on 
the shaft of the femur. But a patient who is short- 
ened by disease can keep his head at this level only 





Fig. 



Fig. i 




% 



Ki 



A 



lig. 



Figs. 116-119. — Proposed Device for Restoring Height in the Sitting 
Position (1S98). 

by supporting his body on the femoral shaft, at the 
cost of considerable effort in the constrained attitude 
seen in Fig. 119. When fatigue finally intervenes 
he will subside into the easy attitude seen in Fig. 
116, in which the head is depressed as the result of 
his spinal shortening. In suitable cases this may 
perhaps be prevented by the apparatus suggested, 
but yet to be constructed. 

Paraplegia. — An occasional and very troublesome 
complication of Pott's disease of the spine is para- 



212 GROWTH AND DEFORMITY. 

plegia, occurring early or late in the disease, accom- 
panying disease of the upper rather than the lower 
regions, varying in seventy from slight tremors to 
the inhibition of walking, having a gradual or 
sudden beginning with no recognizable immediate 
cause, produced not by pressure from a collection of 
matter or deformed bone, but rather by an extension 
of the inflammation to the membranes of the cord, 
sometimes of brief duration, but in some cases con- 
tinuing a very long time, receding gradually or ceas- 
ing suddenly, recurring repeatedly in some cases, 
entirely irresponsive to treatment of any kind, but 
ceasing spontaneously in nearly every case, and sup- 
posed to be controlled indirectly to some extent by 
mechanical treatment of the deformity. The study 
of this form of paralysis led Mr. Pott to a knowledge 
of the morbid anatomy of the disease which bears 
his name. 

Cervical Abscess. — Pott's disease is not often a 
fatal affection, but when it is seated in the upper 
regions of the spine the addition of an abscess intro- 
duces an element of danger. The vital conduits 
converging in a group at the base of the neck are in 
a peculiar position. Some of them transmit blood 
to and fro; others provide for communication be- 
tween the brain and lower parts of the body, and 
others are ducts for the passage of air and nutritive 
ingesta. At this point they are collected and bound, 



COMPLICATIONS OF POTT S DISEASE. 213 

as in a sheaf, by muscular and fibrous structures and 
together they seek admission to the cavity of the 
chest through a gate formed by the body of the sec- 
ond dorsal vertebra, the clavicles, the manubrium, 
and the first and second ribs. An abscess arising in 
carious bone follows the direction of least resistance. 
It is usually harmless, but when it burrows from the 
cervical vertebrae downward in this narrow space it 
is a menace to life. It is not probable that a soft 
tumor of this kind can fatally occlude the trachea, 
whose firm walls render it practically incompressible 
except by severe external violence. But the wind- 
pipe may be flooded by a sudden purulent discharge 
into the pharynx, or fatal spasm of the glottis may 
be induced by interference with the pneumogastric 
nerve. It is not easy to determine the immediate 
cause of sudden death in cases of this kind, which 
give rise to reasonable anxiety and demand an early 
life-saving operation. 

Psoas Abscess. — In another region a burrowing 
abscess may cause, not a fatal event, but serious 
deformity and disability. A slight contraction of a 
psoas muscle, indicating the migration of pus, and 
being perhaps the first sign of Pott's disease, may in- 
crease in extent and firmness until it leaves the pa- 
tient crippled by flexion of the thigh, not unlike that 
following hip disease, differentiated from it by the 
presence of normal motion in every direction except 



214 GROWTH AND DEFORMITY. 

extension, and responsive to similar methods of treat- 
ment. The presence of a psoas abscess may be 
detected through the abdominal wall thoroughly re- 
laxed by flexion of the thighs. In a thin patient the 
lumbar vertebrae and the promontory of the sacrum 
may readily be made out. Comparing the two sides 
deep exploratory palpation will show that the iliac 
f o'ssae are equally clear if matter is absent ; but if an 
abscess is taking this route, the hand will be distinct- 
ly arrested in its descent into the iliac fossa of one 
side. In other regions the abscesses of Pott's dis- 
ease are insignificant. They may be treated indi- 
rectly by giving strict attention to the welfare of the 
diseased bone in which they have their origin. As in 
disease of the hip or knee the result of a case of 
Pott's disease may not be affected by direct treat- 
ment of this complication. 

Case XVIII. — Cold Abscess of Uncertain Origin. 
— A girl, twelve years old, presented in May, 1902, a 
strange appearance caused by a fluctuating tumor of 
each natis. A third tumor, which simulated hernia 
so closely that a truss had been applied, occupied the 
left groin. Pressure on either tumor emptied it and 
increased the tension of the others. Pointing pres- 
ently followed in the groin, and an eruption occurred 
in July without local symptoms or the appear- 
ance of blood. Collapse of the tumors followed a 
great discharge of the fluid common in cold ab- 



COMPLICATIONS OF POTTS DISEASE. 215 

scesses. Treatment was expectant, except that a 
plaster-of- Paris jacket was worn, unadvised, for sev- 
eral months. The sinus closed after flowing for ten 
months, leaving a scar attached to Poupart's liga- 
ment. The tumors were thought to have had 
their origin in disease of the lumbar or sacral verte- 
brae. General reaction caused anxiety for several 
months, but without much interference with the pa- 
tient's activity and strength. The symptoms grad- 
ually and entirely disappeared during a vacation in 
the country. Other organs escaped disease, and in 
October, 1903, menstruation had been established 
and health was completely restored. The scar and 
a slight typical rotating lateral curvature were the 
only abnormal signs found in July, 1904. 

Tuberculous action not very infrequently produces 
in the sternum an anterior deformity analogous to 
the posterior one of Pott's disease. 

Case XIX. — Caries of the Sternum. — In contin- 
uation of Case XIV. (pp. 178, 179): a fluctuating tu- 
mor appeared over the upper part of the sternum in 
December, 1880, the child being under treatment for 
disease of the left hip in the third stage. A month 
later it opened spontaneously with discharge of puru- 
lent semi-fluid. The sinus remained open for two 
years and ten months. Six years after it closed the 
resulting scar measured two inches by one inch and 
a half. It was superficial except at a depressed point 



216 GROWTH AND DEFORMITY. 

where it was attached to the manubrium. Caries 
at the junction of this bone with the gladiolus had 
left a marked deformity with a salient angle of one 
hundred and fifty degrees. The disease at this 
point was attended by no symptoms and required no 
special treatment. It pursued its course while the 
abscesses connected with the hip were alternating 
between eruption and quiescence. Their final clos- 
ure followed that of the sternal sinus after an inter- 
val of five years. In 1895. five years after recovery 
from hip disease, the right kidney became affected 
and was operated on in July, 1897. After a con- 
siderable interval, in which the young woman was 
active and bore the appearance of perfect health, 
the remaining kidney was included and death soon 
followed in January, 1900. Her mother bore scars 
from early disease of the left ankle and tarsus. It 
would seem that there must have been some unde- 
tected reason for the tenacity of the tuberculous pos- 
session in this case, or for its return after it had sur- 
rendered its -hold on the bony structures of the hip 
and thorax. 



CHAPTER X. 

LATERAL CURVATURE OF THE SPINE. 

It is doubtful whether the physicians of antiquity 
recognized lateral curvature of the spine as a distinct 
affection. Cases in which the deformity was mode- 
rate they probably passed over as unimportant, and 
when rotation evolved a large kyphosis, as it does in 
rare instances, they may have resorted to the crude 
methods of forcible reduction which they applied, 
regardless of pathological conditions, to the deform- 
ity of Pott's disease. A knowledge of vertebral 
caries and spinal rotation was postponed to modern 
times. The latter adds a peculiar serpentine ele- 
ment to the appearance of a curving spine which 
could hardly have escaped the attention of early ob- 
servers, although the first* description of it seems 
to have been written by Dr. Dods in 1824. The 
manner of its production has been the subject of 
ingenious speculation and has caused many honest 
differences of opinion among medical men. The me- 
chanics of this interesting puzzle seem to elude the 
understanding very much after the manner of a diffi- 
cult proposition in algebra. For this reason prob- 
ably the true explanation of this phenomenon failed 

217 



218 



GRO WTH AND DEFORMITY. 



for a long time to receive general recognition. Many 
a page has been given to the discussion of the cause 
of rotation, which would have been unwritten if more 
weight had been given to the observation that when 
the column curves, one part of it fails to move lat- 
erally as promptly as another part. The tardy por- 
tion is the posterior section which, with its spinous 
and other processes, is incorporated in the posterior 
wall of the chest and abdomen. The freely moving 
part is the anterior section, where the vertebral 

bodies, with nothing on either 
side to interfere, are at liberty 
to move either to the right or 
to the left in a cavity occupied 
by unresisting viscera. The 
bisection of this great cavity 
into two deep sulci is evident 
in an autopsy. The projec- 
tion into it of the spinal col- 
umn is seen in Fig. 120. A 
hundred times a day, whenever the trunk bends for 
any reason, the column curves and the vertebral 
bodies swing over to one side or the other while 
the processes, being restrained, linger near the me- 
dian plane. The result is rotation. 

A tragical illustration of this action of the spinal 
column occurred when President Garfield fell be- 
fore the pistol of a lunatic. It is believed that the 




Fig. 120. — Horizontal 
Section of Trunk. (Alex- 
ander Shaw, 1842.) 



ROTATING LATERAL CURVATURE. 219 

noise of the first shot attracted the President's atten- 
tion and caused him to look behind over his right 
shoulder. Hastening to avoid succeeding shots he 
strongly bent his body toward the left. This action 
threw the vertebral bodies far to the right where they 
received the second fire directly from behind. The 
direction of this fatal shot is represented by an arrow 
in Fig. 123. When the victim fell from concussion 
of the cord the straightening column gave an appar- 
ent deflection to the track of the ball. Many a wild 
animal, whose vertebral bodies are easily found by a 
shot, has unexpectedly gained its feet and escaped 
after a fall thus produced. 

Hypothetical and Actual Vertebral Rotation. — Rota- 
tion, in general, may take place on a central, on a 
peripheral, or on a remote or foreign axis. This 
movement on a central axis 
is seen in the vertebra rep- 
resented in Fig. 121. It is 
evidently not the rotation of 
lateral curvature. Rotation 
on a peripheral axis is per- \} 
formed by the vertebra seen 
in Fig. 122. This movement 
is exemplified in those cases in 
which the bodies describe a 
marked curve, while the spinous processes adhere in 
a straight line to the median plane. Aside from 




Fig. 121. — Vertebra Rotating 
on a Central Axis. 



220 



GROWTH AND DEFORMITY. 



these exceptional cases vertebral rotation in lateral 
curvature takes place around a remote axis, as is 




Fig. 122. — Vertebra Rotating on a Peripheral Axis. 

shown in Fig. 123. This action gives to all sections 
of the vertebral column a participation in the curva- 
ture, which is greatest in the anterior section and 




Fig. 123. — Vertebra Rotating on a Remote Axis (1876). 

least in the posterior section, while the intermediate 
sections have more curvature as the anterior limit of 



ROT ATI XG LATERAL CURVATURE. 221 

the bones is approached and less as their posterior 
limit is approached. 

Rotating curvature is seen in the deportment un- 




Fig. 124. — Spine without Curve or 
Rotation. 



Fig. 125. — Rotating Curvature. 



der pressure of the preparation seen in Figs. 124, 
125, and 126. The bones are kept in line by a me- 
tallic rod which threads the round fenestra, made 



222 GROWTH AND DEFORMITY. 

from copper wire, which is seen in Fig. 127. The 
position of the rod is seen in Fig. 128. It is flattened 
in order to give it only lateral flexibility. A succes- 
sion of spiral wire springs serves to keep the poste- 




Fig. 126.— Double Rotating Curvature (1876). 

rior section of the column near the median plane, 
just as it is restrained in the living body by being a 
part of the structures composing the posterior wall of 



ROTATING LATERAL CURVATURE. 223 

the cavity. When the column receives downward 
pressure it exhibits rotating curvature, seen in Fig. 
125, and when the middle vertebra is restrained, 




Fig. 127. Fig. 128. 

Figs. 127, 12S. — Isolated Parts of Preparation Seen in Fig. 124. 

there is a compensating curve and a compensating 
rotation, seen in Fig. 126, as they occur in a healthy 
or in a diseased spine. 

Rotation and Curvature Inseparable. — Rotation is 
not only a constant, but the most important, feature 
of the deformity from every point of view. It was 
formerly a question whether rotation or curvature 
was the primary deviation ; but it is clear that they 
occur together, and that in the thoracic and abdomi- 
nal regions the spine cannot curve without rotation. 
Exceptions to this are thought to occur in the de- 



224 GROWTH AND DEFORMITY. 

formity which follows collapse in certain serious af- 
fections of the lungs. It is also clear that the degree 
of rotation increases and decreases with the degree 
of curvature. In the upper dorsal region the slight 
beginning curve to the right is marked by a begin- 
ning rotation, in which the body of the vertebra is 
displaced farther toward the right than the processes. 
Lower down the curvature and the rotation increase 
with equal steps, and then, the extreme being passed, 
they decrease together till a neutral point is reached. 
Here there is no curvature. The vertebra at this 
point is in equilibrium in the median plane with ro- 
tation neither to the right nor to the left. Passing 
below the neutral point there is a curve to the left in- 
stead of to the right, marked by rotation opposite, of 
course, to that found above. Farther down still, the 
compensating curvature and the compensating rota- 
tion increase together in the lower dorsal and lumbar 
regions, and then they decrease till they disappear 
together in the lower lumbar and sacral vertebrae. 
The whole forms the sigmoid curve, to which rota- 
tion imparts a graceful and animating sinuosity. 

The Internal Greater Than the External Curve. — 
As the anterior section of the column departs farther 
from the median plane than the posterior section, the 
full extent of the deviation is not indicated by the 
curve seen in the line of the spinous processes. If 
these show a marked curve, it is certain that the 



DIA GNOSIS OF LA TERAL CUR VA TURE. 225 

bodies execute a still greater curve, unseen, in the 
cavity. Cases are not infrequently observed, exem- 
plifying rotation on a peripheral axis, in which the 
processes show absolutely no deviation, while the 
curving of the bodies throws the ribs, the scapulae, 
and the transverse processes into asymmetry. It is 
noteworthy that the Effect of Rotation on the Torso has 
been overlooked by ancient and modern sculptors of 
the nude figure. When the trunk bends laterally, 
rotating curvature of the spine brings into promi- 
nence unexpected masses of muscle, which would 
have given action where it is missing in the marble 
and bronze, although seen in the gymnasium. It is 
traceable in the bodies of leopards and such animals 
when they turn the corners of their narrow cages 
where it lends a subtle grace to their serpentine 
promenades. 

DIAGNOSIS. 

Misleading Tumors Caused by Rotation. — Rotation 

not only throws into relief unexpected masses of 

muscular fibres, but it also is responsible for a variety 

of mysterious tumors which stand ready to lead the 

most wary diagnostician astray. In the celebrated 

case of Dr. Gideon Mantell, whose spinal curvature 

was recognized only post mortem, rotation produced 

what seemed to be an abscess in the lumbar region, 

which Mr. Liston was prepared to open, with the 
i5 



226 GEO WTH AND DEFORMITY. 

acquiescence of Mr. Brodie. Other consultants 
thought it was a tabulated tumor connected with the 
bodies of the vertebrae. As time passed, and as no 
change appeared in the tumor, it was suggested that 
" the matter was becoming firmer or concrete, and 
that the abscess was inclined to shrink, as abscesses 
sometimes do, and disappear." Cases are recorded 
in which aspiration had been tried in vain, and 
others in which evacuation had been advised and 
postponed. In the case of a patient who was pre- 
sented to a medical society, a tumor was said by 
one observer to be cystic and by another an en- 
largement of the spine of the scapula. Another 
speaker said that on a previous occasion it had dis- 
appeared under an anaesthetic, leaving the inference 
that it was the result of muscular spasm. It was in 
fact a muscular mass brought into prominence by 
spinal rotation. Advancement of the left side of the 
chest gives to the mammary gland the appearance of 
hypertrophy, while a more accentuated prominence 
over the cardiac region simulates the deformity caused 
by an aneurysmal tumor. In Dr. Man tell 's case the 
curvature was confirmed by changes in the shape of 
the bones, and the tumor was permanent. This is true 
in regard to some of the misleading tumors men- 
tioned. Others of them, however, are transient, alter- 
nately appearing and vanishing with changes in the 
patient's attitude, which now produce curvature and 



DIAGNOSIS OF LATERAL CURVATURE. 227 

rotation, and again cause them to disappear. When 
the tumors caused by rotation affect this elusive 
quality they may be regarded as phantoms. 

Recognition of Rotation. — It is important, therefore, 
to be able to eliminate the influence of rotation when 
considering certain tumors of doubtful origin. A 
useful diagnostic method may be practised by palpa- 
tion of the chest between the palms, which may re- 
veal a longer diagonal diameter in one direction than 
in the other, thus betraying rotation even in cases in 
which the spinous processes are in a straight line. 
When rotation makes prominent the angles of the 
ribs on the rigrt side behind, the same movement 
brings out a prominence on the left side of the chest 
in front. An increase in the diagonal diameter in 
this (the first) direction is thus produced. At the 
same time, the same movement of rotation depresses 
the angles of the ribs on the left side behind, and also 
flattens the right side of the chest in front. A de- 
crease of the diagonal diameter in this (the second) 
direction is thus caused. Since the same movement 
of rotation increases one diameter and decreases the 
other, a very moderate amount of rotation may, and 
often does, produce a difference in these diameters 
which is readily detected by bimanual compression of 
the chest applied diagonally, first in one direction and 
then in the other. With care the presence of a very 
slight rotation may be detected in this way. 



228 



GROWTH AND DEFORMITY. 



Aside from occasional doubt as to the origin of 
some of the results of rotation, the recognition of 
lateral curvature is a simple matter. In the absence 
of symptoms and general reaction, diagnosis depends 

wholly on want of sym- 
metry, which is first seen 
in the shoulders or hips, in 
many cases by a casual ob- 
server after an indefinite 
duration. 

Sciatica. — Since it is cus- 
tomary in orthopaedic work, 
and especially in lateral 
curvature, to lay more stress 
on signs than on symptoms, 
it is well to consider a 
peculiar spinal deviation 
accompanying sciatica. In 
this affection the subjective 
symptom of pain should 
Overshadow all else, but it is 
accompanied by a deform- 
ity, or spinal deviation, remarkably suggestive of 
lateral curvature, with a distinct displacement of 
the axis of the chest forward and to the opposite 
side, as in Fig. 129. This patient, a professional 
man, forty-seven years of age, suffered severely 
from sciatica. When the photograph was taken he 




Fig. 129 — Right Sciatica Sim- 
ulating Sacro-iliac Disease 
and Lateral Curvature (1885). 



DIAGNOSIS OF LATERAL CURVATURE 229 

had been disabled for eight months. Ten months 
later he unexpectedly recovered, after having re- 
ceived a great variety of advice and treatment in 
different parts of the country. Pain, disability, and 
spinal deformity were absent after his recovery, until 
he died of disease of the kidneys, after a short illness 
at the age of fifty-four. It is noteworthy that the 
displacement of the axis of the chest was always to 
the left, and never to the right, and that the patients 
were men, in a number of observed cases, as well as 
in the photographs in which a peculiar deviation is 
seen in the treatises of Sayre, Moore, Whitman, 
and others. The painful symptoms may extend to 
the toes, arresting passive extension of the knee 
when the hip is flexed, and flexion of the hip when 
the knee is extended. A spinal deviation having 
this origin may be useful as a diagnostic sign. 

Sacro-iliac Disease.— It is important to note that 
the attitude of the patient in sciatica and his inabil- 
ity or disinclination to use the affected limb may 
lead to a mistaken diagnosis, not only of lateral cur- 
vature of the spine, but also of sacro-iliac disease. 
This affection is allied on one side with Pott's dis- 
ease and on the other side with hip disease. It may 
receive neither the mechanical support which Pott's 
disease requires nor protection from the weight of 
the body by ischiatic support. A suitable mechani- 
cal environment for a tuberculous sacro-iliac joint is 



230 GROWTH AND DEFORMITY. 

to be found therefore only in recumbency. It is not 
easy to see why this disease is so rare when cases of 
the two affections with which it is allied are so com- 
mon. An explanation may be hazarded as follows: 
When the case is mild, the stability of the affected 
bones and their relation of mutual support may lead 
to recovery before the disease is recognized; and 
when the case is severe, disability doubtless compels 
a resort to recumbency, which in time may lead to 
recovery before a positive diagnosis can be made. 
The recognition of this disease is exceptionally diffi- 
cult on account of the deep situation and the immo- 
bility of the joint. It has been frequently said 
that the affection is likely to be complicated by ab- 
scesses, and that it has a generally unfavorable prog- 
nosis. Further knowledge is necessary before these 
statements may be accepted as beyond question. 

Various Theories oj Rotation. — Many explanations 
of the occurrence of rotation have been presented. 
It was formerly held that one of the functions of the 
articular processes was to prevent undue lateral 
excursions of the bodies of the vertebrae, and that 
pressure from a faulty position too long continued 
would change their shape and allow the bodies to 
rotate from the want of customary lateral opposition. 
Rotation was thus made to appear as the result of a 
morbid change in the vertebrae themselves, and not 
of influences derived from their relation to the wall 



DIAGNOSIS OF LATERAL CURVATURE. 231 

of the cavity. According to this view, if the left su- 
perior articular process of the ninth dorsal, for in- 
stance, yields to pressure and allows the left side of 
the eighth to advance, the same yielding would al)ow 
the left side of the ninth to recede, and there would 
be no disturbance either way, and of course no rota- 
tion; and as the inferior, as well as the superior, 
processes must yield to absorption from pressure, the 
ninth will rotate toward the left in obedience to the 
absorption of its superior process, and at the same 
time toward the right in response to the giving way 
of its inferior articulating process, and there would 
be no rotation in either direction. The cause of this 
movement may be sought, not in changes in the ver- 
tebrae themselves, but rather in a foreign agent, such 
as mural limitation of the mobility of the spinous 
processes. It has also been thought that the ante- 
rior part of the column has expansibility, and the 
posterior part compressibility, and that in curvature 
the expanding bodies seek the convexity where there 
is less pressure, leaving the compressed processes in 
the concavity where there is more pressure; but 
these spinal motions are so sharp and distinct that 
they could not be produced in this way. 

At a meeting of the British Medical Association 
held in 1864, it was suggested that "the twisting is 
purely the mechanical consequence occasioned in 
the deviated or curved spine by bending it forward." 



232 



GROWTH AND DEFORMITY. 



In criticism of this theory it may be recalled that the 
spine bent forward and at the same time laterally 
may not be said to have two curves, one antero- 
posterior and the other lateral, but rather one curve 




Fig. 130. 




Fig. 131. 



Fig. 132. 



Fig. 



33- 



Figs. 130-133. — Rotation not Affected by the Flexion or Extension of the 
Curved Spine (1901). 



produced by the resultant of two forces, one acting 
antero-posteriorly and the other laterally. The curve 
thus produced is partly antero-posterior and partly 
lateral, but it is still a simple curve, and as such it 



DIAGNOSIS OF LATERAL CURVATURE. 233 

has no power to initiate a rotary movement. Fig. 130 
represents an imitation of the vertebral column made 
of India rubber, in order to determine whether antero- 
posterior variations of the spine do or do not ex- 
ert an influence on the production of the rotation 
which accompanies lateral curvature. The central 
pin is presented point blank to the camera in each 
exposure in order to secure the same point of view 
throughout the series. Fig. 131 shows a lateral curve 
without flexion or extension, Fig. 132 shows a lateral 
curve with flexion, and Fig. 133 shows a lateral curve 
with extension. Rotation does not appear in the 
series, except in Fig. 133. In this figure a careless 
arrangement of the object before the camera has 
given a quartering view of the central pin, which has 
resulted in what appears to be a slight rotation of the 
column. The effect of this mistake does not vitiate 
the demonstration that rotation is independent of 
flexion or extension. It simply calls attention to the 
necessity of holding the same point of view in the 
different members of such a series. 

The True Theory of Rotation.— To find the cause 
of rotation the attention may be directed away from 
the column itself and its vertebrae. It has no intrin- 
sic attributes inclining it to rotate, and no relation of 
some of its parts to others that can contribute to the 
production of this peculiar action. The cause of 
rotation is aptly explained by a reference to the ex- 



234 GROWTH AND DEFORMITY. 

trinsic agency of the chest wall, which imposes a re- 
straint on a part of the spine without affecting other 
parts. This theory is in accord with all the con- 
ditions found. It explains the facts that rotation 
attends the transient curves of health and the con- 
firmed curvature of disease, that it is absent in the 
cervical region, and that it crosses the median plane 
in company with the compensating curve. The ob- 
servation made in 1876 that rotation was produced 
in this way was thought to be new, but Mr. Noble 
Smith, in 1882, referred to the work of Mr. Rogers- 
Harrison, who made the same observation in 1842. 
It is so simple, when it is apprehended, and such a 
complete and satisfactory interpretation of a common 
clinical incident that it has probably occurred to 
others, and very likely may be found in writings be- 
fore the time of Mr. Rogers- Harrison. 

Incidental Rotating Curvature, when it occurs as 
the result of an habitual one-sided attitude or carriage 
of the body, may be sufficiently arrested by timely cor- 
rection of the bad habit. It is assumed in an uncon- 
scious effort to maintain equilibrium menaced by the 
loss of an arm or the collapse of a lung. It accom- 
panies shortening of a leg by accident or disease, and 
may then be lessened or removed by factitious 
lengthening of the short limb, as in Figs. 108 and 
109 (p. 181), where compensation is made by a book 
placed under the foot. 



TREA TMENT OF LA TERAL CUR VA TURE. 235 

Typical Lateral Curvature. — The greater number of 
cases, however, occur without any known cause, ex- 
cept such as may be found in muscular inability to 
sustain the impending weight, which overcomes the 
spine and causes it to sag more and more till it pre- 
sents an instance of typical lateral curvature. The 
etiology of this affection remains obscure, and its 
treatment is still so unsatisfactory that when the de- 
formity is confirmed by changes in the bones it is 
generally believed to be beyond the reach of any 
attempts at reduction. It is fortunate, therefore, that 
the affection does not compromise longevity, or in- 
terfere with a life of industry and activity. It might 
be argued, but not too seriously, that a lateral cur- 
vature is an agreeable departure from conventional 
symmetry, an attractive feature, to be placed in the 
same category with a slight cast, or squint, which 
has been thought to add piquancy to a regular face. 
It may not be denied that it repeats the curved line 
of beauty, or that rotation carries an expression of 
serpentine grace. 

TREATMENT. 

Although it may not be possible to make an es- 
tablished curvature disappear, careful treatment 
may be expected partly to reduce the deformity or 
to render it less noticeable. Especially should treat- 
ment be thorough when a case shows any indication 



236 GROWTH AND DEFORMITY. 

of assuming a rare form in which the angles of the 
ribs are pushed backward by rotation until the re- 
sulting kyphosis rivals that of a neglected case of 
Pott's disease. It may not be concluded because the 
deformity of lateral curvature is not as a rule offen- 
sive, or attended with disability and danger to life, 
that the treatment of this affection is to be lightly 
considered. The possibility of an excessive protru- 
sion of the angles of the ribs should be in the mind, 
to encourage earnest and careful treatment. When 
one of these rare cases is fully developed, an exten- 
sive and very prominent kyphosis, quite near the 
middle line of the back, has its profile made up by a 
succession of accentuated angles of rotated ribs, and 
not, as in Pott's disease, by the projection of the 
spinous processes of carious vertebrae. The de- 
formed and deflected processes may, with care, be 
isolated and counted near the crest of the costal 
kyphosis and almost overhung by it. The stature is 
reduced by a descent of the thorax and its lodgment 
on the pelvic bones, as in Pott's disease. This con- 
dition is serious enough to call for every resource of 
watchfulness, prevention, and treatment. 

The wish is often expressed that apparatus could 
be so made that it would do, with certain plastic de- 
formities, what can be done so easily by the hands. 
It would seem that rotation could be diminished, 
temporarily at least, by rolling the chest forcibly 



TREA TMENT OF LA TERAL CUR VA TURE. 237 

between the palms, but it is at present beyond the 
power of mechanical therapeutics to produce and 
prolong this effect, and especially to oppose simulta- 
neously the primary and the secondary deviations. 
If, however, either curve could be reduced in this 
way, compensation would bring the whole column 
into a straight line. 

Antero-Posterior Pressure. — For many years the 
opinion, which received the early advocacy of Dr. 
Lee, has been under consideration that antero-poste- 
rior pressure, long continued and forcible, would be 
curative in lateral curvature, as it is in Pott's disease, 
by transferring the pressure of superincumbent 
weight from the anterior to the posterior section of 
the column. There is a suggestive analogy in the 
relations of the vertebrae in the two affections. In 
Pott's disease the anterior part of the bone is carious, 
and a brace transfers pressure to its posterior part, 
which is unaffected. In lateral curvature the ante- 
rior portion departs from the median plane, and a 
brace might transfer pressure to the posterior por- 
tion, which adheres to the median plane. Further- 
more, pressure applied directly from behind would 
meet the transverse processes of the convex side 
which are rotated backward, before it could reach 
those of the concave side, which are rotated forward. 
It would therefore directly and positively oppose 
rotation. The plan is certainly attractive from a me- 



238 GROWTH AND DEFORMITY. 

chanical point of view. When a trial of it was made 
in 1876 and 1877 it was found to be easily practicable. 
It was difficult, however, to continue the treatment 
long enough to note whether it could be relied on to 
produce positively favorable results. The method 
would be justified and commendable if the pathology 
and prognosis of this affection were as serious as 
those of Pott's disease. This plan may be compared 
and contrasted with the common method of making 
lateral pressure on the projecting ribs, which is open 
to the objection that although such pressure is to all 
appearances reasonably applied to reduce an obvious 
projection, it is applied to the ribs, which show an 
incidental deformity, and not to the curving spine, 
which is the seat and origin of the trouble. A re- 
view of the anatomy of the part recalls the fact that 
the ribs are attached to the spine so near to its poste- 
rior and so far from its anterior section that pressure 
on them, applied with any degree of force, would in- 
crease rotation or at least prevent its reduction. If 
pressure could be made by invading the cavity 
(which is as yet impossible), and pushing laterally and 
forcibly against the bodies of the vertebrae, it is con- 
ceivable that both curvature and rotation could be 
opposed by one motion. 

Treatment Based on Clinical Observations. — It seems 
proper, therefore, to decline to make the application 
of a brace the rule of practice, subject of course to 



TREA TMENT OF LA TERAL CUR VA TURE. 239 

the proverbial exceptions which are said to prove a 
rule. But something should be undertaken not to 
reduce the curvature entirely, which is very seldom 
done, but to modify it and its incidental deformities 
and to prevent an increase of the trouble. 

Recumbency. — In the course of clinical observa- 
tions it is evident, at the first examination, that the 
curvature is diminished when the weight of the up- 
per part of the body is removed by recumbency in 
the prone position. Rotation and its incidental de- 
formities also largely disappear with the curvature. 
But these phenomena return in full force when the 
patient rises. These changes doubtless take place 
unseen when standing alternates with the supine 
position, which hides the back from view. It follows 
that a growing child, affected with lateral curvature, 
should be led to occupy the recumbent position as 
much of the time as possible, so that the increment 
incidental to natural growth may be correctly placed 
and favor symmetry. " Just as the twig is bent, the 
tree's inclined." 

The question has been debated whether this affec- 
tion could occur in a child whose attitude from birth 
had been absolute and uninterrupted recumbency. 
If downward pressure by the weight of the upper 
part of the body were the only direct cause, there 
could of course be no lateral curvature in a child who 
had never been placed in the erect position. But 



240 GROWTH AND DEFORMITY. 

muscular contraction is also to be counted as one of 
the direct causes. It may be recalled that the mus- 
cles of the trunk assume a general tonic condition 
when any considerable movement is made elsewhere, 
in order to afford a firm base of action for motions of 
the head or in the extremities. Probably very few 
movements take place in any part of the body with- 
out a longitudinal compression of the spine. This 
would favor the production of lateral curvature as 
certainly as compression made by the weight of the 
head and upper part of the body. 

Muscular contraction has, however, a limited effect 
in this direction, and superincumbent weight must 
still be considered as the principal direct cause of 
lateral curvature. Recumbency, practised several 
hours daily, is therefore to be retained as an impor- 
tant part of systematic treatment. In the supine 
position an air pillow, inflated to an increasing de- 
gree as the patient becomes accustomed to its use, 
should occupy such a position under the back as to 
maintain lordosis. This may be considered as an 
imitation of the effect of the proposed antero-poste- 
rior brace, the action of which transfers pressure 
from the more affected to the less affected section of 
the spine. This position should be maintained dur- 
ing sleep so far as is practicable. An air pillow of 
convenient size is " No. 2," which measures about 
eighteen inches by ten inches. 



TREA TMENT OF LA TERAL CUR VA TURE. 241 

Suspension. — Observations being resumed, it is 
seen that the curvature disappears even more 
promptly and completely when the patient suspends 
herself from an overhead bar than when she lies 
down, and that when the hands relinquish the bar 
there is a sudden return of the curvature and all of 
its incidental deformities. Suspension should there- 
fore be added to the list of important therapeutic 
agents. There should be no muscular effort beyond 
that required to keep the fingers flexed on the bar. 
The body may swing gently in suspension, as a 
means of timing the exercise, seven vibrations back- 
ward and forward measuring one-quarter of a minute, 
which is long enough for each effort at the begin- 
ning. A simple doorway bar may be conveniently 
used for a number of exercises, half a dozen or so, 
with suitable intervals, on rising in the morning. 
More time and effort may be expended at bedtime, 
to be followed by the night's rest. In the routine of 
the day the bar should be in use as much as is prac- 
ticable. The customary apparatus for suspension 
by the head and the axilla? will give facility and thor- 
oughness to these exercises. 

Chest Expansion.— It will be observed that the 

chest is expanded during suspension. The sternal 

ends of the ribs being attached to the bar through 

the intervention of the arm, forearm, and hand, their 

vertebral ends are drawn downward by the weight of 
16 



242 



GRO WTH AND DEFORMITY. 



the body and lower limbs, producing forced inspira- 
tion in a very positive manner. The effect of deep- 
ening and facilitating inspiration by the practice of 
suspension has received well-merited attention. Dr. 

Henry G. Davis made it a 
part of a method by which 
he believed that he had 
demonstrated the curabil- 
ity of phthisis pulmonalis. 
The physiological and me- 
chanical considerations 
which give to suspension 
its value as a means of de- 
veloping the chest are illus- 
trated in Sylvester's meth- 
od of resuscitating those 
about to perish by asphyx- 
iation. It may also be 
recalled that audible sus- 
piration is made when the 
conditions are favorable by 
a cadaver drawn up and laid supine on the floor 
of the dissecting-room, after transit from below 
while suspended by the arms. It is said that pa- 
tients seek relief in asthmatic paroxysms by grasp- 
ing the top of a door in the absence of a more 
convenient support. Dr. French, of Portland, Maine, 
in 1877 introduced a respiratory brace, shown in 




Fig. 134.— 
Orthopnoea 



Respiratory Brace for 
. (Dr. French, 1877. J 



TREA TMENT OF LA TERAL CUR VA TURE. 243 

Fig. 134, for the relief of orthopnoea. With this 
device in use suspension may be conveniently grad- 
uated in severity as the patient is seated and can 
at will put more or less of his weight on the sup- 
porting straps. Suspension applied as a part of 
the treatment of lateral curvature, coinciding, as it 
will, with the period of growth, may reasonably be 
expected to produce a lasting effect on the size of the 
thorax and capacity of the lungs. This accession of 
respiratory ability cannot but react favorably on the 
general health and especially on the muscular sys- 
tem, whose failure is apparently a link in the chain 
of causes of lateral curvature. A further considera- 
tion of this form of exercise will also show that it 
provides what has been most diligently sought, a 
Method of Directly Opposing Rotation, an element of 
the deformity which lateral pressure from without is 
unable to affect, except adversely. Suspension op- 
poses rotation from within by overfilling or inflat- 
ing, by a forced development of its contents, the cav- 
ity upon which rotation encroaches. 

Rest. — Observations being resumed, it will be seen 
sooner or later that fatigue or weakness increases the 
appearance of deformity. During an indisposition, 
or after a long walk or wearisome journey, more than 
the customary degree of curvature is noticed, while 
if the patient is not tired and is sustained by good 
sleep and digestion, the general well-being finds ex- 



244 GROWTH AND DEFORMITY. 

pression not only in the face but also in less curva- 
ture and rotation. From this observation may be 
derived the practical suggestion that throughout the 
growing period overexertion should be avoided. 
The child should not be told to " sit up straight," but 
to lie down. Moderation should govern the daily 
routine, the pastimes, and all the duties, mental and 
physical, of child life at home and at school. 

Sequence of Causes of Rotating Curvature. — From 
this review of clinical phenomena a probable se- 
quence of the causes of rotating curvature may be 
formulated in these words: The diminution of the 
cavity of the chest is caused by the rotation; the 
rotation in caused: (i) by an unequal lateral dis- 
placement of the anterior and posterior sections of 
the spinal column; and (2) by the curvature; the 
curvature is caused by a failure of the muscles to 
hold the column erect under its natural burden ; the 
failure of muscular action is caused by defective in- 
nervation, the cause of which is as yet conjectural. 



INDEX. 



PAGE 

Abduction, adduction, and flexion measured by goniometer . . 1 68, 169 

Abduction an early sign of hip disease 143 

Abduction and apparent lengthening 117,161,162,165-167 

Abduction desirable after hip disease 161 

Abnormal and normal rhythm, diagrams of 185,186 

Abnormal rhythm an early sign of hip disease 142, 180 

Abnormal rhythm producing deformity and lameness . 176, 177, 179, 185 
Abnormal rhythm unconsciously adopted to secure protection . . . 177 

Abscess and contraction, flexion produced by psoas 213 

Abscess of uncertain origin 214,215 

Abscess, scar following desiccation of 133 

Abscess simulating hernia 214 

Abscesses and visceral degeneration 139 

Abscesses, cold 131-134, 214 

Abscesses, doubtful significance of 139 

Abscesses, spontaneous opening of 131, 132, 214 

Abscesses treated by intelligent expectation 137-139,215 

Absorption of abscesses 132,133,226 

Acquirement of correct rhythm by instruction and military drill . 187, 188 
Acquirement of correct rhythm favored by growth .... 180, 186, 187 

Activity out of doors secured by mechanical treatment 70 

Adams (London, 1820-1900), Mr. William 73, 113 

Adduction and apparent shortening .... 161, 162, 165-167, 170, 171 

Adduction and flexion illustrated by jointed dolls 163, 164 

Adduction deporable after hip disease 161 

Adduction producing lateral curve of spine 171 

Adhesive plaster applied to untwist anterior part of foot 13 

Adhesive plaster in treatment of club-foot 6-8, 12-14 

Adhesive plaster made from India-rubber and other tropical gums by Eyre 

(1848) and Martin (1877) 75 

Adhesive plaster prehension an American invention 92 

Adhesive plaster so applied as to avoid dermatitis 113,114 

245 



246 INDEX. 

PAGE 

Adhesive plaster to prevent rust u, 36 

Adhesive plaster traction in hip disease . . . . . 113,114 

Adhesive plaster traction used in fractures by Gross and Crosby . . 89, 90 
Adhesive plaster traction used in hip disease by Davis and Sayre . . 90 

Adhesive plaster used in club-foot by Cheselden and Gross 8 

Advanced hip disease, three unmistakable signs of 145,146 

Advantage of long leverage at knee-joint 77, 80, 102, 176 

Adverse lever at ankle-joint 44 

Aged, Pott's disease in the 191 

Ailments of feet, minor 31, 32 

Air pillow and recumbency in lateral curvature 240 

American hip splint, the 91, 92 

Amputation and exsection, Fergusson on 67 

Amputation for infantile paralysis 35 

Amputation in hammer toes 31 

Amputation in white swelling of knee 82, 83, 137 

Amputation of anterior part of foot by American aborigines .... 40 

Amputation of knee in Hilton's case of hip disease 100, 101 

Anaemia applied to check growth of longer limb 182 

Analogy in fracture and hip disease 106 

Andrews (Chicago, 1824-1904), Dr. Edmund 127 

Andry (de Boisregard, 1 658-1 742), Nicolas 2 

Aneurysmal varix, hyperemia and lengthening produced by . . . .182 

Angular curvature an incorrect but convenient term 192, 193 

Angular projection a demonstration of Pott's disease 189, 197 

Ankle a corner around which tendons of leg pass 30 

Ankle constriction a cause of flat-foot 29, 30 

Ankle disease, Dr. Schapp's case of . . . 86 

Ankle disease protected by wearing a peg-leg 86 

Ankle disease treated on expectant plan by Dr. Gibney 86 

Ankle-joint, adverse lever at 44 

Ankylosis in white swelling of knee, fear of 75 

Ankylosis not caused but prevented by fixation 68-70, 107 

Ankylosis of shoulder and of hip, vicarious mobility in. . . . 125, 161 

Ankylosis prevented by subduing inflammation 68-70, 107 

Anterior muscles of thigh, counter-pressure in paralysis of . . . . 35, 36 
Anterior muscles of thigh, hyperextension of knee in paralysis of . . . 35 

Antero-posterior pressure applied to oppose rotation 237, 238 

Antero-posterior pressure in lateral curvature advocated by Lee . . . 237 

Apparatus improved by introduction of Bessemer steel 3 

Apparatus not requiring cushions, pads, and wadding .54 



INDEX. 247 

PAGE 

Apparent and real or structural shortening 147, 170, 171, 180 

Apparent lengthening and abduction 117,161,162,165-167 

Apparent shortening and adduction .... 161,162,165-167,170,171 

Arrest of function, inflammation subdued by 68, 74 

Artificial limb, ischiatic crutch used as an 127,128 

Artificial limb supporting weight on ischium 126 

Asymmetrical walking promoting deformity 176,177,179 

Audible suspiration by cadaver after suspension 242 

Average life of pathological doctrine, Adams on 73 

Axillary and ischiatic support compared 127 

Axis of head displaced in cervical Pott's disease 194-196 

Axis, rotation of vertebra on central, peripheral, and remote . . . 219-221 

Bad position in hip disease, cause of 173, 174 

Ball-and-socket joint depending on muscles for stability 143 

"Bang" stroke, nails to be cut by 32 

Bartow (Buffalo, N. Y.), Dr. Bernard 66 

Batchelder (New York, 1 784-1868), Dr. John Putnam 90 

Bauer (New York and St. Louis, 1814-98), Dr. Louis 90, 99 

Bed by ischiatic crutch, affected limb practically put to . . . 150, 201 

Bell (Edinburgh, 1775-1842), Mr. Charles 98, 101, 200 

Bessemer steel increasing efficiency of mechanical treatment .... 3 

Bicycle riding and protection 126 

Bimanual palpation of chest in diagnosis of rotation 227 

Blanchard (Chicago), Dr. Wallace 81 

Blandin (Paris, 1798-1849), Phillippe Frederic 103 

Bodily weight affecting treatment of club-foot 7-9,14-17,22 

Bonnet (Lyon, 1802-58), Amedee 102, 106 

Bow-legs and knock-knee corrected more easily in recumbency. . . 79, 80 
Bow-legs and knock-knee treated by pressure and counter-pressure . . 80 

Bow-legs and knock-knee, growth affecting treatment of 79 

Boy wearing hip splint thought he was "sitting down" 113 

Boy's ruse to escape painful examination 151 

Brace likened to outside skeleton 54, 207 

Braces in treatment of lateral curvature, question of .... 237, 238 

Bradford (Boston), Dr. Edward Hickling 16, 202 

Brake promoting fixation by hip splint 105 

Brisement force likely to promote tuberculous action 124 

Broca (Paris, 1824-80), Pierre Paul 90, 182 

Brodie (London, 1783-1862), Mr. Benjamin Collins . . . .75, 90, 99, 

103, 106, 126, 226 



248 INDEX. 

PAGE 

Bronson (New York, 1827-97), Dr. J onn Oscar 90 

Buck (New York, 1807-77), Dr. Gurdon 90, 105 

Bucket release and lever release 38,39 

"Buck's extension" producing fixation 105 

Cadaver making audible suspiration after suspension 242 

Calcaneus rarely congenital, talipes . 40 

Calcaneus, weight transferred from toe to upper part of leg in . . 47, 49 

Callus indicating relapse to' varus 15 

Caries and shortening caused by overexertion after hip disease . . . 129 

Caries of sternum producing anterior projection 215, 216 

Cause of bad position in hip disease 173, 174 

Cause of rotation demonstrated by preparation of vertebral column 221-223 

Cause of rotation recognized by Rogers-Harrison 234 

Causes of lateral curvature, sequence of 244 

Centre of gravity of body in relation to joint diseases . . . . 100, 101 

Certain recovery from tuberculous joint disease 67, 68, 72 

Cervical Pott's disease, crepitus in 196 

Cervical Pott's disease, horizontal vision by extension of head in . 194, 195 

Cervical Pott's disease illustrated in Young's treatise 196 

Cervical Pott's disease, forward displacement of axis of head in . 194-196 

Chance (London, 1807-95), Mr- Edward John 103 

Chapman (Monte Vista, Colorado), Dr. Norman Hyde 126 

Character of pain of hip disease 104 

Charcot's knee relieved by prosthetic apparatus 53 

Charring effect of inflamation in a joint 69 

Cheselden (London, 1688-175 2), Mr. William 8 

Chest and abdomen bisected by vertebral column, cavity of . . . . 218 

Chest expansion, rotation opposed by 243 

Chest in diagnosis of rotation, bimanual palpation of 227 

Childhood tolerating inconvenience of mechanical treatment . 55, 56, 63, 72 

Circle in joint disease, vicious 93 

Clinical features in Pott's disease, unexpected 197 

Clinical observations determining treatment of lateral curvature . . 238 

Closure of sinuses, effect of temporary 141 

Club-feet useful in locomotion, uncorrected 16 

Club-foot affected by weight of body 7-9, 14-17, 22 

Club-foot at home, management of 15 

Club-foot brace, key to application of 7 

Club-foot, division of tendo Achillis in 18 

Club-foot, flexible 10 



INDEX. 249 

PAGE 

Club-foot, forcible correction of 26 

Club-foot, growth and weight of body in treatment of spastic . ... 16 

Club-foot, mechanical details of treatment of 6, 7, 10-13 

Club-foot, neglected, relapsed, and inveterate 16 

Club-foot, prosthetic brace for 17 

Club-foot requiring crutches or ischiatic support 17 

Club-foot requiring operation, inveterate 16 

Club-foot treated by continuous leverage 16, 17 

Club-foot treated by pressure and counter-pressure 5, 6,11 

Club-foot treated with adhesive plaster 6-8, 12-14 

Club-foot treated with adhesive plaster by Cheselden and Gross ... 8 

Club-foot treated with plaster of Paris 5 

Club-foot, weight of body transferred from toe to upper part of leg in 12 

Coates (Philadelphia, 1797-1881), Dr. Benjamin Horner 102 

Cold abscesses 131-134, 214 

Colles' fracture, mechanical disadvantages in treatment of .... 102 

Comfort dictating position of limb in hip disease 173,174 

Comparative value of traction and protection in hip disease .... 122 

Comparison of axillary and ischiatic support 127 

Comparison of hip disease and fracture 106 

Comparison of joint disease and fracture by David de Rouen . . . 106 

Comparison of the two sides important in diagnosis 144, 145 

Compensatory curvature and compensatory rotation . . . 223, 224, 234 

Composite sensation of kneeling and standing 47 

Composite sensation of sitting and standing 112, 113 

Condensation of soft parts a diagnostic sign of hip disease 145 

Congenital club-foot, details of treatment of 6, 7, 10-13 

Congenital club-foot, juvenile growth aiding reduction of 13 

Congenital club-foot promptly treated by Willard 5 

Congenital dislocation of hip, equine foot in single 148 

Congenital dislocation of hip not disabling 147, 148 

Congenital dislocation marked by lordosis 193, 194 

Congenital dislocation, "sailor gait" in 148 

Congenital talipes calcaneus rare 40 

Conservative surgery of present day 67 

Constriction of ankle a cause of flat-foot 29, 30 

Continuous leverage in club-foot 16, 17 

Convenience dictating position of limb in hip disease . . .173, 174, 176' 

Cook (Hartford, Conn.), Dr. Ansel Granville n 

Cooper (San Francisco, 1822-62), Dr. Elias Samuel 103. 

Corner of ankle turned by tendons of leg muscles 30. 



250 INDEX. 

PAGE 

Corns 31 

Correct rhythm acquired by instruction and military drill . . . 187, 188 

Correct rhythm easily acquired during growth 180, 186, 187 

Correction of congenital club-foot, juvenile growth facilitating ... 13 
Correction of deformity of hip disease, unconscious . . . . 178,179 

Correction of hammer toes facilitated by growth 32 

Correlation of traction and fixation 102, 104 

Costal kyphosis in extreme lateral curvature 236 

Counting time in acquirement of normal rhythm 187 

Coxa vara, removing weight of body in 148 

Coxa vara requiring osteotomy 148 

Crabs and lobsters presenting outside skeletons 54 

Crepitus in cervical Pott's disease .....196 

Crooked rod straightened by pressure and counter -pressure . . . . 176 

Crooked rod straightened by traction and counter-traction 1 75 

Crosby (Manchester, N. H., 1794-1874), Dr. Josiah 89, 9a 

Crustaceans presenting outside skeletons 207 

Crutch, ischiatic in, 120, 121 

Crutches in club-foot 17 

Crutches in joint disease, Brodie on use of 126 

Cup and ball illustration of short leverage 102 

Cured, hip disease managed rather than 89 

Curvature and rotation, compensating 223, 224, 234 

Curvature and rotation inseparable, spinal 223 

Curvature not reduced by pressure on ribs . . . . . / 238 

Curvature of bodies coincident with normal position of processes . 219, 225 

Curvature reduced by factitious lengthening of short limb 181 

Curved line of beauty in scoliosis 235 

Cushions, pads, and wadding not necessary in apparatus 54 

Dancing lessons in acquirement of normal rhythm 187 

Date of diagnosis affecting prognosis in joint disease 70, 149 

David (de Rouen, 1737-84), Jean Pierre 106 

Davis (New York, 1807-96), Dr. Henry Gassett . . . . 90,91,172,242 
Definition of intelligent expectation in treatment of joint disease . . 68 

Definition of limping, or lameness 184 

Definition of orthopaedic surgery, Andry's 2 

Definition of rest in treatment of joint disease 68 

Deformities, growth a factor in paralytic 51, 52 

Deformities, growth affecting the treatment of rachitic 79 

Deformity of hip disease, growth favoring reduction of ... . 159, 180 



INDEX. 251 

PAGE 

Deformity of hip disease illustrated by Marsh's diagrams . . . 162 

Deformity of hip disease illustrated by manikins and silhouettes . 163-167 

Deformity of hip disease reduced by Ridlon 172 

Deformity of hip disease, unconscious correction of 178,179 

Deformity of joints, juvenile growth a factor in prevention of . . . 72 
Deformity of lateral curvature less in recumbency and suspension, 239-241 

Deformity reduced by weight and pulley 117,172 

Deformity, traction and counter-traction in reduction of extreme . . 175 

Demonstration in orthopaedic practice, physical 63,161 

Deplorable effects of dorsal Pott's disease 199, 201 

Deportment in diagnosis of Pott's disease 197 

Derivation of orthopaedic . . v 

Dermatitis prevented by alternate application of adhesive strips . 1 13, 1 14 

Desault (Paris, 1749-95), Peter Joseph 99, 107 

Description of hip limp 171 

Description of rotation by Dods in 1824 217 

Desiccation of abscess followed by a scar 133 

Details of application of hip splint in third stage 115-117 

Details of mechanical treatment of Pott's disease 206-209 

Details of treatment of congenital club-foot 6,7,10-13 

Detmold (New York, 1808-94), Dr. William 20 

Diagnosis of cervical Pott's disease illustrated by Young 196 

Diagnosis of hip disease by William Ross 1 4 ( ) 

Diagnosis of rotation by bimanual palpation of chest 227 

Diagnosis of tumor in Gideon Mantcll's case, mistaken 226 

Diagnosis of white swelling of knee by Romaine 82 

Diagnostic sign of hip disease, Steele's 145 

Diagonal palpation of chest, diagnosis of rotation by 227 

Diagrams of normal and abnormal rhythm 185, 186 

Diet in hip disease 118, 17S 

Difficulty of direct mechanical reduction in hip disease .... 174-176 

Difficulty of fixing hip-joint, Bell on 98, 99, 101, 200 

Disadvantage of short leverage at hip-joint 101,102,176 

Disadvantages of human foot, mechanical 26,27 

Discontinuing treatment of hip disease 128, 129 

Discovery of motion in hip disease 146, 147 

Discovery of reflex action in hip disease 143, 144 

Disease of wrist, elbow, and shoulder 124,125 

Dislocation of hip, congenital 147, 148, 180, 193, 194 

Dispensary, Schapps on equipment of orthopaedic 59, 60 

Displacement of fixative brace prevented by special device .... 79 



252 INDEX. 

PAGE 

Division of tendo Achillis, Hibbs on . „ 46 

Division of tendo Achillis in club-foot „...•. 18 

Dods (London), Dr. Andrew . 217 

Dods' recognition of rotation ... 217 

Dolls illustrating flexion and adduction, jointed 163,164 

Doorway bar for suspension in lateral curvature 241 

Dormant muscular power developed by apparatus 60, 61 

Dow splint, Dr. Taylor's . 127 

Drainage of region of initial foci in hip disease 139,140 

Drill and instruction in acquirement of correct rhythm .... 187, 188 

Dundreary's witticism based on philosophy and humor 100 

Duplicate braces ...... 55 

Duration of treatment of hip disease . 93,138 

Duration of treatment of tuberculous joints 71, 72 

Early diagnosis in joint disease, Taylor on importance of . . . .. 70 

Early diagnosis in Pott's disease 89, 90, 196, 197 

Early diagnosis of white swelling of knee 81, 82 

Early sign of hip disease, abnormal rhythm an 142,180 

Early stage of infantile paralysis, recumbency and graduated ex- 
ercises in 34 

Early treatment of congenital club-foot, Willard on 5 

Elbow disease 123, 124 

Elongation of tendo Achillis inevitable in paralysis 40 

Environment affecting course of hip disease, mechanical . . . 87, 88 
Environment, recovery of diseased knee hastened by improved me- 
chanical 74 

Environment, tuberculous action influenced by mechanical . . . 62, 123 
Epiphyseal hyperasmia causing lengthening in knee disease .... 84 
Equilibrium preserved by lordosis in Pott's disease . . . . . 193,194 

Equine foot favored by short tendo Achillis . 184 

Equine foot in single congenital dislocation of hip 148 

Equine foot neutralizing structural shortening 154, 183-185 

Equipment of orthopaedic laboratory 59, 60 

Erect position in infantile paralysis, postponement of 34 

Exact science in orthopaedic practice, methods of precision and, 63, 73, 163 

Examination, boy's ruse to escape painful 151 

Exanthemata, deportment of sinuses in 141 

Exempt from tuberculous joints, upper extremities comparatively . 70, 123 

Expansion of chest, rotation opposed by 243 

Expectant plan in ankle disease, Gibney on . . 86 



INDEX. 253 

PAGE 

Expectant treatment of tuberculous joint disease 4, 67, 68 

Expectation in abscesses 137-139, 215 

Expectation in third stage of hip disease 159 

Expectation in treatment of joint disease, definition of 68 

Expectation in tuberculous joint disease 67, 68 

Exsection and amputation, Fergusson on 67 

Extension of head, horizontal vision in Pott's disease preserved by . 194, 195 

Extension shoe 183, 185 

Extension, traction formerly called 89 

Extreme lateral curvature producing costal kyphosis 236 

Eyre (Derby, England), Mr. Douglas Fox 75 

Falling and perpetual recovery in locomotion, perpetual . . . 41, 51 

Fear of ankylosis 75 

Fear of wounding tendons, subcutaneous tenotomy postponed by . 3 

Feeding in hip disease 118,178 

Feet in club-foot and hip disease, outlines of 22,155,156,158 

Feet, minor ailments of 31, 3a 

Fergusson (London, 1808-77), Mr. William 67 

Fever, synovitis of hip-joint after typhoid 148 

Fibula, mistaken diagnosis of fracture of 145 

Figure in Pott's disease, growth facilitating improvement of . . 204, 205 

Finnell (New York, 1826-90), Dr. Thomas Constantine 90 

Fixation and protection in white swelling of knee 74*85 

Fixation and release of jointed brace for leg 37~39 

Fixation and traction, correlation of 102, 104 

Fixation by weight and pulley or hip splint demonstrated . 104, 105 

Fixation, healthy joint not injured by 69, 70 

Fixation, inflammation subdued by 69, 70, 107 

Fixation initiated by reflex contraction and confirmed by ankylosis . 171 

Fixation of hip-joint, Bell on 98,99,101,200 

Fixation of knee by pressure and counter-pressure 76 

Fixation preventing not causing ankylosis 68-70, 107 

Fixation produced by " Buck's extension " 105 

Fixation with hip splint promoted by brake 105,106 

Fixative brace, flexion of knee corrected by 77 

Fixative brace to knee, key to application of 78 

Flat-feet benefited by throwing weight of body on heel 30 

Flat-feet requiring rest 29 

Flat-foot caused by constriction of ankle 29, 30 

Flat-foot caused by growth and increasing weight 28 



254 INDEX. 

PAGE 

Flexible club-foot 10 

Flexion and adduction illustrated by jointed dolls 163,164 

Flexion and extension of spine, rotation independent of . . . 232, 233 

Flexion of foot, normal 21 

Flexion of hip disease causing lordosis 166,167,171,194 

Flexion of knee after operation, Townsend on 83 

Flexion of knee corrected by fixative brace 77 

Flexion of knee measured with goniometer 86 

Flexion produced by psoas abscess and contraction 213 

Foci drained in hip disease, region of initial 139, 140 

Foot, growth promoting recovery of deformed 62 

Foot measured with goniometer, flexion of 21 

Foot, normal flexion of 21 

Foot straight, stamping a 10, 13 

Forced extension and plastic dressings in Pott's disease .... 208, 209 

Forcible correction in Pott's disease 206 

Forcible correction of club-foot • . . . 26 

Ford (London, 1 746-1809), Mr. Edward 106 

Fracture and hip disease compared 106 

Fracture and joint disease compared by David de Rouen 106 

Fracture and joint disease, paradox in treatment of 106 

Fracture of longer bone to neutralize structural shortening 181 

Fracture treated with adhesive plaster by Gross and Crosby . . . 89, 90 
Frame for treatment of Pott's disease, Bradford's portable .... 202 

Freiberg (Cincinnati), Dr. Albert Henry 182 

French (Portland, Maine, 1837-97), Dr. George Franklin 242 

Friedreich's disease, talipes of . 53 

Function, inflammation subdued by arrest of ....... 68, 74 

Function of muscular system of joint, twofold 100 

Functional ability facilitated by growth, acquisition of 160 

Functional result after hip disease, Hilton's illustration of 159 

Functional result after third stage of hip disease 158-160 

Gait, protection by ischiatic crutch promoting symmetrical . . 177-179 

Gait, rhythm an important element of 118, 187 

Garfield, rotation of spine in case of President 218,219 

Gastralgia in Pott's disease 197 

Gestation, lordosis of 194 

Gibney (New York), Dr. Homer 193 

Gibney (New York), Dr. Virgil Pendleton 78, 86, 97 

Goldthwait (Boston), Dr. Joel Ernest 194 



INDEX. 255 

PAGE 

Goniometer in measurement of abduction, adduction, and flexion 168, 169 

Goniometer in measurement of flexion of foot 21 

Goniometer in measurement of flexion of knee 86 

Goniometer in measurement of motion in hip disease . . . 146, 147 

Graceful sinuosity imparted to sigmoid curve by rotation 224 

Graduated exercises and recumbency in early stage of infantile 

paralysis 34 

Gross (Philadelphia, 1805-84), Dr. Samuel David 8, 89 

Growth a factor in congenital club-foot 5,8,13,22,26,62 

Growth a factor in prevention of deformity after joint disease .... 72 

Growth a factor in recovery 1 

Growth a factor in removal of structural shortening 182 

Growth, acquirement of correct rhythm facilitated by . . . 180, 186, 187 

Growth affecting results of hip disease 159, 180 

Growth affecting treatment of paralytic and rachitic deformities . 5 1, 52, 79 

Growth aiding development of paralyzed muscles 60, 61 

Growth and increasing weight causes of flat-foot, rapid 28 

Growth and recumbency in treatment of lateral curvature .... 239 

Growth, correction of hammer toes facilitated by 32 

Growth dictating changes in apparatus 13, 14, 206 

Growth favoring effect of rest and suspension in lateral curvature . 243, 244 

Growth favoring recovery from Pott's disease 191 

Growth favoring reduction of deformity in hip disease .... 159, 180 
Growth, improvement of figure in Pott's disease facilitated by . . 204, 205 
Growth in Pott's disease encouraged by mechanical treatment . . . 210 

Growth in spondylitics, H. L. Taylor on 210 

Growth in treatment of spastic club-foot 16 

Growth, introduction of functional ability favored by 160 

Growth, natural resistance to disease aided by 67 

Growth of bone and hyperemia, Broca and Helferich on, 182 

Growth promoting recovery from joint disease 67, 72 

Growth, recognition of varying rates of 2 

Growth, repair the repetition of . 1 

Growth, rest, and repair, Hilton on 1,4 

Growth, treatment to be more urgent in periods of rapid 2 

Gum in place of oxide of zinc in adhesive plaster 75 

Gymnasium, spinal rotation seen in 225 

Habitual traumatism, resolution of inflammation prevented by . . 70 

Hammer toes, amputation in 31 

Hammer toes, growth facilitating correction of 32 



256 INDEX. 

PAGE 

Hancock (London, 1809-80), Mr. Henry . 114, 115 

Hayward (Boston, 1 791-1863), Dr. George 89 

Head displaced forward in cervical Pott's disease, axis of . . . 194-196 

Head extended to preserve horizontal vision 194-196 

Healthy joint not injured by fixation 69, 70 

Heel in diagnosis of hip disease, pounding the . . . ... . . . 151 

Helferich (Greifswald), Heinrich 182 

Hernia simulated by abscess 214 

Hibbs (New York), Dr. Russell Aubra 46 

High sole and low sole in actual shortening 183 

High sole for well foot with protective apparatus ....... 126 

Hilton (London, 1804-78), Mr. John 1, 4, 100, 101, 159 

Hip and knee deformities reduced by pressure and counter-pressure 175, 176 

Hip disease, abnormal rhythm an early sign of 142, 180 

Hip disease and fracture compared 106 

Hip disease and knee disease, pendent limb in 82,122 

Hip disease, " apparent " deformities in 163 

Hip disease, character of pain of 104 

Hip disease, condensation of soft parts a diagnostic sign of . . . . 145 
Hip disease cured by amputation of knee, Hilton's case of . . 100, 101 
Hip disease described by Hancock, patient third stage of . . 114, 115 

Hip disease, diet in 118,178 

Hip disease, discontinuing treatment of . 128, 129 

Hip disease, discovery of motion in 146, 147 

Hip disease, discovery of reflex muscular action in . . . . . 143,144 

Hip disease, duration of treatment of 93, 138 

Hip disease, effect of reflex muscular action in . 144, 149, 150, 171, 172 

Hip disease, historical notes on treatment of 88 

Hip disease illustrated by manikins and silhouettes, deformity of 163-167 
Hip disease illustrated by Marsh's diagrams, deformity of . . . . 162 

Hip disease managed rather than cured 89 

Hip disease, mathematical appreciation of results of 160-169 

Hip'disease, mechanical environment affecting course of .... 87, 88 

Hip disease, motion less important than position in 161 

Hip disease, natural repair in 87, 138 

Hip disease, pain in knee in 142,143,149,191 

Hip disease promptly recognized by Ross 149 

Hip disease, recovery insured by mechanical treatment of 138 

Hip disease, Steele's diagnostic sign of 145 

Hip disease treated with weight and pulley by Brodie 90, 99 

Hip disease, unconscious correction of deformity of .... 178, 179 



INDEX. 257 

PAGE 

Hip disease, unmistakable signs of advanced 145, 146 

Hip disease, weight and pulley in third stage of 117 

Hip-joint, Bell on difficulty of fixing 98,99,101,200 

Hip-joint, disadvantage of short leverage at 101,102,176 

Hip-joint, position not determined by morbid anatomy of 174 

Hip limp, description of 171 

Hip splint, Andrews' 127 

Hip splint at home, rule for management of 119,120 

Hip splint, description of 107-109 

Hip splint in third stage, details of application of 115-117 

Hip splint, length of perineal strap key to use of 109,110,119 

Hip splint or weight and pulley, fixation produced by ... . 104, 105 

Hip splint thought he was "sitting down," boy wearing 113 

Hip, vicarious mobility in ankylosis of 161 

Hip, weight of body to be removed from diseased 87 

Historical notes on treatment of hip disease 88 

Holcombe (New York, 1 828-1 904), Dr. William Frederick .... 90 

Holmes (Boston, 1809-94), Dr. Oliver Wendell 41, 50 

Home management of club-foot brace 15 

Home management of white swelling of knee 85,86 

Home, rule for management of hip splint at 119, 120 

Horizontal vision preserved by extension of head in cervical Pott's . 194, 195 

Horseback riding and protection 126 

Horseshoe forged with an extension 11 

Horse's lameness concealed by cruel device 184,185 

Human foot criticised by Savarin, construction of 27 

Human foot, mechanical disadvantages of 26,27 

"Human wheel" 41 

Humor and philosophy in Dundreary's witticism 100 

Hunter (London, 1728-93), Mr. John 71 

Hyperemia and growth, Broca and Helferich on 182 

Hyperaemia and lengthening, aneurysmal varix producing . . . . 182 

Hyperaemia induced in joint disease by Freiberg 182 

Hyperaemia of epiphysis, lengthening caused by 84 

Hyperaemia promoting growth of shorter limb 182 

Hyperextension in white swelling of knee 77, 83-85 

Hyperextension of knee by pressure and counter-pressure . . . 35,77 
Hyperextension of knee promoting stability in paralysis and disease 35, 84 
Hyperextension of normal knee 84 

Iliac fossae, psoas abscess recognized bv palpation of 214 

17 



258 INDEX. 

PAGE 

Uio-ischiatic line to trochanter, relation of 169 

Immovable movable joint 77, 172 

Importance of comparing the two sides in diagnosis 144, 145 

Importance of mechanical surgery, Stephen Smith on 58 

Incidental rotating, or lateral, curvature 234 

Inconstant lameness a sign of joint disease 81, 82, 142 

India-rubber used in adhesive plaster by Eyre and Martin .... 75 

Infantile paralysis, hyperextension of knee desirable in 35 

Infantile paralysis in upper extremities ^ 

Infantile paralysis, postponement of erect position in 34 

Infantile paralysis, recumbency and graduated exercises in early stage of 34 

Infantile paralysis, rolling gait of jolly tar in 185 

Infantile paralysis, spontaneous recovery from ^ 

Inflamed abscesses 134-136 

Inflammation, ankylosis prevented by subduing 68-70, 107 

Inflammation of joint prolonged by use 73 

Inflammation, structures of joint charred by 69 

Inflammation subdued by arrest of function 68, 74 

Inflammation subdued by fixation of joint 69, 70, 107 

Inflammation subdued by rest 68, 69, 74 

Ingrowing nails 32 

Initial foci in hip disease, drainage of region of 139, 140 

Innutrition and tuberculous joint disease 64, 65 

In-sole, protection of shoe by steel 12 

Intelligent expectation in abscesses 137-139,215 

Intelligent expectation in disease of wrist, elbow, and shoulder . 124, 125 

Intelligent expectation in joint disease, definition of 68 

Intelligent expectation in third stage of hip disease 159 

Intelligent expectation in tuberculous joint disease ..... 4, 67, 68 
Intervertebral pressure by posterior force, redistribution of . 203, 209, 237 

Inversion of toe in club-foot 15 

Inveterate club-foot requiring operation 16 

Inveterate relapsed and neglected club-foot 16 

Ischiatic and axillary support compared 127 

Ischiatic crutch in, 120, 121 

Ischiatic crutch, affected limb practically put to bed by . . . 150, 201 

Ischiatic crutch as an artificial limb 127, 128 

Ischiatic crutch in rachitic deformities of legs 80 

Ischiatic crutch in treatment of knee disease 81 

Ischiatic crutch in treatment of ununited fracture 128 

u Ischiatic crutch," Prince^ 127 



INDEX. 259 

PAGE 

Ischiatic support in club-foot 17 

Ischiatic support, traction discontinued in favor of 120, 121 

Ischium receiving weight in artificial limbs 126 

Jacket, plaster-of-Paris 208 

Joint, charring effect of inflammation on structures of 69 

Joint disease affected by weight of body 123 

Joint disease and fracture, paradox in treatment of 106 

Joint disease, duration of treatment of 71, 72 

Joint disease, growth promoting recovery from 62, 67, 72 

Joint disease, Hunter on muscular action in 171,172 

Joint disease, intelligent expectation in treatment of tuberculous . 4, 67, 68 
Joint disease less serious when remote from centre of gravity . . 100, 101 

Joint disease, neuro-muscular element of 171 

Joint disease requiring early diagnosis 70 

Joint disease tabulated in upper and lower extremities 123 

Joint disease treated by induction of hyperaemia by Freiberg .... 182 

Joint disease, vicious circle in 93 

Joint not injured by fixation, healthy 69, 70 

Jointed brace for leg with fixation and release 37~39 

Joints, natural repair and recovery of tuberculous 67 

Joints of lower extremity exposed to violence in locomotion . 123, 124, 126 

Jolly tar assumed in infantile paralysis, rolling gait of 185 

Jury-mast suspension in Pott's disease 203, 209 

Juvenile growth a factor in prevention of deformity of joints .... 72 
Juvenile growth aiding treatment of congenital club-foot 13 

Key to application of club-foot brace 7 

Key to application of fixative brace to knee 78 

Key to application of hip splint, length of perineal strap the . 109, 1 10, 1 19 

Knee corrected by fixative brace, flexion of 77 

Knee disease and hip disease, pendent limb in 82,122 

Knee disease attended by subluxation 82, 85 

Knee disease, flexion following operation for 83 

Knee disease formerly requiring amputation 82, 83 

Knee disease, home management of 85,86 

Knee disease, reflex muscular action in 81,82 

Knee flexion reduced with plaster of Paris by Gibney 78 

Knee, hyperextension of normal 84 

Knee, hyperextension promoting stability of 35, 84 

Knee in hip disease, Hilton's case of amputation of 100, 101 



260 INDEX. 

PAGE 

Knee in hip disease, pain in 142,143,149,191 

Knee-joint, advantage of long leverage at 77, 80, 102, 176 

Knee-joint fixed by leverage 77, 85, 176, 202, 203 

Knee, key to application of fixative brace to 78 

Knee, protection and fixation in white swelling of 74, 85 

Knee, weight of body to be removed from diseased 74 

Kneeling and standing, composite sensation of 47 

Knock-knee and bow-leg corrected more easily in recumbency . . 79, 80 

Knock-knee and bow-leg, growth affecting treatment of 79 

Knock -knee and bow-leg treated by leverage . . 80 

Knock-knee and bow-leg, weight of body to be removed in . . . . 79, 80 

Krackowizer (New York, 1822-75), ^ r - Ernst 90 

Kyphosis in extreme lateral curvature, costal 236 

Kyphosis, scoliosis, and lordosis 193 

Laboratory, equipment of orthopaedic 59, 60 

Laced legging in place of roller bandage, Taylor's 112,113 

Lameness concealed by normal rhythm 178,185 

Lameness, definition of 184 

Lameness in horse concealed by cruel device 184, 185 

Lameness produced by abnormal rhythm 185 

Lameness replaced by symmetrical walking 186 

Landmarks of spine, Whitman's 192 

L'ankylophobie 75 

Lateral curvature, costal kyphosis in rare cases of 236 

Lateral curvature in recumbent child, muscular action a factor in . 239, 240 

Lateral curvature, incidental and typical ..." 234, 235 

Lateral curvature, muscular compression a cause of . . . . 239, 240 

Lateral curvature not a disabling affection 235 

Lateral curvature, question of braces in treatment of 237, 238 

Lateral curvature, sequence of causes of 244 

Lateral curvature simulated by sciatica ......... 228, 229 

Lateral curvature treated by suspension and rest 241, 243 

Lateral curvature, unrecognized cases of 225, 226 

Lateral curve in Pott's disease 189 

Lateral curve of spine produced by adduction of hip disease . . . . 171 

Lead-pipe stiffness of diseased joint 172 

Leaden sole for affected foot 126 

Lee (Philadelphia), Dr. Benjamin 237 

Legging substitute for roller bandage, Taylor's laced . . . . 112, 113 
Length of perineal strap key to use of hip splint 109, no, 119 



INDEX. 261 

PACK 

Lengthening in knee disease produced by epiphyseal hyperaemia . 84 

Lengthening of short limb, curvature reduced by factitious .... 181 
Lengthening produced by abduction, apparent . 117, 161, 162, 165-167 
Lengthening produced by aneurysmal varix and hyperaemia . . 182 

Leopards and other animals exhibiting rotating curvature 225 

Lesauvage (Caen, 1 778-1852), Edme 99 

Lever at ankle-joint, adverse ... 44 

Lever release and bucket release 38, 39 

Leverage applied to fix knee-joint 77,85,176,202,203 

Leverage at hip-joint, disadvantage of short 101,102,176 

Leverage at knee-joint, advantage of long 77,80,176 

Leverage illustrated by cup and ball, short 102 

Leverage in treatment of club-foot 511,512,516,517 

Leverage in treatment of knock-knee and bow-legs 80 

Leverage in treatment of Pott's disease 203 

Limb in treatment of knee disease and hip disease, pendent . . 82,122 

Limping, definition of 184 

Liston (London, 1 794-1846), Mr. Robert 99*225 

Little (London, 1810-94), Dr. William John 19, 20 

Lobster and crab, outside skeleton of 54 

Location of sinuses in hip disease 135, 139, 140, 153 

Locomotion and traumatism inseparable 123, 124, 126 

Locomotion impaired by long tendo Achillis 40, 46 

Locomotion, mechanics of 41,50,51,84 

Locomotion, perpetual falling and perpetual recovery in . . . 41,51 

Locomotion, rhythm of human 118,142,148,185-187 

Locomotion unimpaired by moderately short tendo Achillis . 21,46 

Locomotor ability in uncorrected club-foot, Bradford and Lovett on . 16 

Locomotor ataxia, talipes valgus of 53 

Long leverage at knee-joint, advantage of 77, 80, 176 

Long tendo Achillis, locomotion impaired by 40, 46 

Longevity not compromised by congenital dislocation of hip. ... 148 

Longevity not compromised by lateral curvature of spine 235 

Lordosis caused by flexion of hip disease 166, 167, 171, 194 

Lordosis in psoas contraction, gestation, and muscular paralysis . . . 194 

Lordosis in treatment of lateral curvature 240 

Lordosis preserving equilibrium in Pott's disease 193, 194 

Lordosis, scoliosis, and kyphosis 193 

Lordosis seen in opisthotonos and congenital dislocation 193 

Lovett (Boston), Dr. Robert Williamson 16 

Low sole and high sole in actual shortening 183 



262 INDEX. 

PAGE 

Lumbar region, mechanical support ineffective in Pott's disease of . . 200 

Macnamara (London, 1834-99), Mr. Charles Nottidge 66 

Malignant disease of vertebrae, Myers on diagnosis of 199 

Management of hip splint at home, rule for 119,120 

Management of spinal brace, rule for 207 

Manikins and silhouettes, deformity of hip disease illustrated by . . 163-167 

Mantell's case, mistaken diagnosis of tumor in Gideon 226 

March (Albany, N. Y., 1 795-1869), Dr. Alden 89, 106 

Marking time in acquirement of normal rhythm 187 

Marsh (London), Mr. Howard 162 

Martin (Paris), Ferdinand 106 

Martin (Boston, 1824-84), Dr. Henry Austin 75 

Mathematical appreciation of results of hip disease 160-169 

Mathematical certainty in orthopaedic practice 161 

Mathematical demonstration of strain on tendo Achillis .... 42-46 
Measurement of deformity of hip disease with goniometer . . . 168,169 
Measurement of flexion of foot with goniometer ........ 21 

Measurement of flexion of knee with goniometer 86 

Measurement of motion in hip disease with goniometer . . . 146, 147 

Mechanical details of treatment of club-foot 6, 7, 10-13 

Mechanical disadvantages in treatment of Colles' fracture . . . . 102 

Mechanical disadvantages of human foot 26, 27 

Mechanical environment affecting course of hip disease .... 87, 88 
Mechanical environment, tuberculous action influenced by . . . 62,123 
Mechanical laws in orthopaedic practice, application of . . . . 63, 162 
Mechanical or operative treatment of tuberculous joint disease . . 65-67 

Mechanical reduction of deformity in hip disease 174-176 

Mechanical support not effective in lumbar Pott's disease .... 200 

Mechanical surgery, Stephen Smith on importance of 58 

Mechanical treatment encouraging growth in Pott's disease .... 210 

Mechanical treatment of hip disease, recovery insured by 138 

Mechanical treatment of Pott's disease, details of 206-209 

Mechanical treatment permitting outdoor activity 70 

Mechanical treatment tolerated by children, inconvenience of 55, 56, 63, 72 

Mechanics of locomotion 41, 50, 51, 84 

Mechanics of production of talipes varus and valgus 51 

Medication in hip disease . 118 

Medicine and surgery, new truths in 3 

Methods of precision and exact science in orthopaedic practice . 63, 73, 163 
Military drill in acquirement of correct rhythm ...... 186-188 



INDEX. 263 

PAGE 

Miner (New York, 1 780-1 863), Dr. William W 9° 

Minor ailments of feet V-->Z 2 

Misleading tumors caused by rotation 225-227 

Mistaken diagnosis of tumor in Gideon Mantell's case 226 

Mobility in ankylosis of shoulder and of hip, vicarious .... 125, 161 

Modifying quadrupedal gait, methods of 11,184,185 

Moore (Minneapolis), Dr. James Edward 229 

Morbid anatomy of hip-joint, inferences from 95~9^ 

Morbid anatomy of hip-joint, position not determined by 174 

Motion in hip disease, discovery of 146, 147 

Motion in hip disease less important than position 161 

Motion in hip disease measured with goniometer 146, 147 

Movable immovable joint 77, 172 

Mural theory of rotation 231 

Muscles aided by growth, development of paralyzed 60,61 

Muscles arresting passive motion by reflex action . . . .81,82, 143,144 

Muscles "on guard" in joint disease 172 

Muscular action in hip disease, discovery of reflex 143, 144 

Muscular action in hip disease, effect of reflex . . 144, 149, 150, 171, 172 

Muscular action in joint disease, Hunter on 171,172 

Muscular compression a cause of lateral curvature, longitudinal . 239, 240 

Muscular system of joint, twofold function of 100 

Muscular wasting an early sign of hip disease ... 143 

Myers (New York), Dr. Thaddeus Halsted 199 

Nails, ingrowing 32 

Nails to be cut by "bang" stroke 32 

Napier (New York), Dr. Charles D wight 202 

"Natural cure" of hip disease 89 

Natural reaction and consolidation in Pott's disease 205 

Natural repair and recovery in tuberculous joint disease 67 

Natural repair in hip disease 87, 138 

Natural resistance to disease aided by growth 67 

Necrosis of shoulder, Paget's case of quiet 125 

Neglected club-foot, prosthetic brace for 17 

Neglected, relapsed, and inveterate club-foot 16 

Neuro-muscular element of joint disease 171 

New truths in medicine and surgery 3 

Nil desperandum in treatment of Pott's disease 201 

No n -deforming club-foot 39 , 40 

Normal and abnormal rhythm, diagrams of 185, 186 



264 INDEX. 

PAGE 

Normal knee, hyperextension of 84 

Normal position of spinous processes coincident with curve of 

bodies 219, 225 

Normal rhythm concealing lameness 178, 185 

Normal rhythm encouraged by protection of the joint .... 177,178 
Normal rhythm preventing deformity 177-179 

Objective signs and subjective symptoms 142, 162, 228 

Old age not exempt from Pott's disease 191 

"On guard " in joint disease, muscles 172 

Operations followed by flexion in knee disease 83 

Operative or mechanical treatment of tuberculous joint disease . . 65-67 

Operative removal of tuberculous deposits 66 

Operative treatment of inveterate club-foot 16 

Opisthotonos an example of lordosis 193 

Orthopaedic, derivation of v 

Orthopaedic laboratory, equipment of 59, 60 

Orthopaedic practice, application of mechanical laws in . . 63, 162 

Orthopaedic practice, mathematical certainty in 161 

Orthopaedic practice, methods of precision and exact science in .6^, 73, 163 

Orthopaedic practice, physical demonstration in 63, 161 

Orthopaedic surgery, Andry's definition of 2 

Orthopaedic surgery as a specialty 61 

Osteoclasis in rachitic deformities, Blanchard on 80, 81 

Osteotomy, deformity of coxa vara corrected by 148 

Outlines of feet in cases of club-foot and hip disease . . 22, 155, 156, 158 

Out-of-door activity secured by mechanical treatment 70 

Outside skeleton, brace likened to 54, 207 

Overexertion after hip disease, caries and shortening caused by . 129, 154 

Overuse and disuse producing deformity 170, 181 

Oxide of zinc replaced by tropical gums in adhesive plaster 75 

Pads, wadding, and cushions seldom necessary in apparatus .... 54 

Paget (London, 1814-99), Mr. James . 125 

Pain absent in early hip disease 151 

Pain and disability absent in Pott's disease, local 197, 198 

Pain in knee in hip disease 142,143,149,191 

Pain in stomach in Pott's disease 142, 191, 192, 197 

Pain of hip disease, character of 104 

Painful examination, boy's ruse to escape 151 

Palpation of chest for discovery of rotation, bimanual 227 



INDEX. 265 

PAGE 

Palpation of iliac fossae, psoas abscess recognized by 214 

Paradox in treatment of joint disease and fracture 106 

Paralysis of anterior muscles of thigh, hyperextension of knee in ... 35 
Paralysis of muscles of thigh, pressure and counter-pressure in . . 35, 36 

Paralysis of quadriceps extensor 34 

Paralysis, recumbency and graduated exercises in early stage of 

infantile 34 

Paraplegia of Pott's disease 211,212 

Parker (New York, 1801-84), Dr. Willard 90 

Passive motion liable to promote tuberculous activity 124 

Pasteboard silhouettes illustrating deformity of hip disease . 165-167 

Pathological doctrine, Adams on average life of 73 

Peg-leg locomotion in talipes calcaneus 39 

Peg-leg protection in ankle disease 86 

Pendent limb in knee disease and hip disease 82, 122 

Perineal strap key to convenient use of hip splint, length of . 109, 1 10, 1 19 

Periods of rapid growth, treatment to be more urgent in 2 

Peripheral axis, rotation of vertebra on 219, 220, 225 

Perpetual falling and perpetual recovery in locomotion 41, 51 

Phantom tumors caused by rotation 227 

Philipeaux (Lyon), Raymond 99, 103 

Philosophy and humor of Dundreary's witticism 100 

Physical demonstration in orthopaedic practice 63, 161 

Physick (Philadelphia, 1768-1837), Dr. Philip Syng 102 

Plane dividing varus and valgus 9 

Plaster in club-foot and hip disease, adhesive . 6-S. 12-14, 9 2 - "3i IJ 4 
Plaster of Paris applied by Gibney to reduce flexion of knee. 78 

Plaster of Paris in club-foot 5 

Plaster-of-Paris jacket 208 

Plastic dressings and forced extension in Pott's disease .... 208, 209 

Portable frame for Pott's disease, Bradford's 202 

Portable frame for Pott's disease, Napier on 202 

Portable frame modified by Whitman 202 

Position in hip disease dictated by comfort and convenience . 174, 176, 177 

Position in hip disease more important than motion 161 

Position not determined by morbid anatomy of hip-joint . . . 174 

Possession, tenacity of tuberculous 216 

Post (New York, 1800-86), Dr. Alfred Charles 90 

Pott (London, 1714-88), Mr. Percivall .... .212 

Pott's disease, Bradford's portable frame for 202 

Pott's disease, details of mechanical treatment of 206-209 



266 INDEX. 

PAGE 

Pott's disease, early diagnosis of 189, 190, 196, 197 

Pott's disease, forcible correction in '.. 206 

Pott's disease, growth facilitating improvement of figure in . . 204, 205 

Pott's disease, growth favoring recovery from 191 

Pott's disease in the aged 191 

Pott's disease, insidious nature of 190, 197 

Pott's disease, lateral curve in 189 

Pott's disease, leverage in treatment of 203 

Pott's disease, local pain and disability absent in 197, 198 

Pott's disease marked by displacement of axis of head, cervical . 194-196 
Pott's disease, mechanical environment a factor in recovery from . . 201 

Pott's disease, mechanical treatment promoting growth in 210 

Pott's disease, nil desperandum in treatment of 201 

Pott's disease, pain in stomach in 142, 191, 192, 197 

Pott's disease, pressure and counter -pressure in treatment of . . . 203 
Pott's disease, prosthetic apparatus for sitting position in . . . 210,211 
Pott's disease, redistribution of pressure by posterior force in . . 203, 209 

Pott's disease, reduction of stature in 210 

Pott's disease, unexpected clinical features in 197 

Pott's disease, wiring vertebral processes in 208 

Pounding heel in diagnosis of hip disease 151 

Precision and exact science in orthopaedic practice, methods of, 63, 73, 163 

Prehension by adhesive plaster an American invention 92 

Preparation of vertebral column demonstrating cause of rotation . 221-223 

Present day, conservative surgery of 67 

Pressure and counter -pressure for deformity of knee and of hip . 175, 176 
Pressure and counter -pressure in bow-legs and knock-knee .... 80 
Pressure and counter-pressure in treatment of club-foot . . . . 5, 6, 11 
Pressure and counter -pressure in paralysis of muscles of thigh . . 35, 36 
Pressure and counter -pressure in treatment of Pott's disease . . . 203 

Pressure on ribs incompetent to reduce curvature 238 

Prevention of ankylosis by fixing joint and subduing inflammation 

68-70, 107 

Preventive and therapeutic, prosthetic apparatus 60 

Prince (Jacksonville, 111., 1816-89), Dr. David 127 

Prognosis in joint disease depending on date of diagnosis .... 70,149 

Projection of sternum produced by caries, anterior 215, 216 

Prosthetic apparatus for neglected club-foot 17 

Prosthetic apparatus for sitting position in Pott's disease . . . 210,211 

Prosthetic apparatus in Charcot's knee 53 

Prosthetic apparatus preventive and therapeutic 60 



INDEX. 267 

PAGI 

Protection and fixation in treatment of white swelling of knee . . 74, 85 
Protection and traction in hip disease, comparative importance of . 122 

Protection by horseback, bicycle, and tricycle riding 1 26 

Protection by ischiatic crutch promoting symmetrical gait .... 177-179 

Protection facilitating return to normal rhythm 177, 178 

Protection from traumatism inducing resolution 122, 123 

Protection in ankle disease secured by peg-leg 86 

Protection in hip disease by flexing knee in silicate bandage .... 126 

Protection in joint disease of lower extremity, methods of 125 

Protection sought by the adoption of abnormal rhythm 177 

Pseudo-hypertrophic muscular paralysis, saddle-back of 194 

Psoas abscess and contraction producing flexion 213 

Psoas abscess recognized by palpation of iliac fossae 214 

Puerperal dislocation of pelvic bones, Goldthwait on 194 

Pumping of joint by hip splint 119 

Quadriceps extensor, paralysis of 34 

Quadrupedal gait, modifications of 11,184,185 

Quiet necrosis of shoulder, Paget's case of 125 

Quiet resolution absent from joints of lower extremities .... 123,124 

Rachitic deformities, Blanchard on osteoclasis in 80,81 

Rachitic and paralytic deformities, growth affecting treatment of 

5 1 . S^, 79 

Rack and pinion of hip splint 106, 114 

Radius of disturbance in joint disease 189 

Raphael (New York, 1818-80), Dr. Benjamin J 90 

Rapid growth, treatment to be more urgent in periods of 2 

Rare cases of lateral curvature, costal kyphosis in 236 

Rate of growth in spondylitics, H. L. Taylor on 210 

Reaction and consolidation in Pott's disease 205 

Reaction and recovery in tuberculous joint disease 72 

Real or structural and apparent shortening . . . . 147, 170, 171, 180 

Recognition of cause of rotation by Rogers-Harrison 234 

Recognition of mechanical surgery, Stephen Smith on 58 

Recovery and perpetual falling in locomotion, perpetual .... 41,51 

Recovery and repair of tuberculous joints, natural 67 

Recovery certain in tuberculous joint disease 67,68,72 

Recovery from infantile paralysis, spontaneous ^1 

Recovery from joint disease promoted by growth 67, 7*2 

Recovery from Pott's disease favored by growth 191 



268 INDEX. 

PAGE 

Recovery, growth a factor in i 

Recovery of diseased knee favored by improved mechanical environ- 
ment 74 

Recumbency and graduated exercises in infantile paralysis .... 34 

Recumbency and growth in lateral curvature 239 

Recumbency in lateral curvature, deformity reduced by . . . 239, 240 
Recumbency in treatment of knock-knee and bow-legs .... 79, 80 

Recumbency in treatment of Pott's disease, Napier on ..... . 202 

Recumbent child, muscular action a factor in lateral curvature of . 239, 240 
Recurrent caries from overexertion after hip disease . . . . . . 129 

Redistribution of intervertebral pressure by posterior force . 203, 209, 237 
Reduction of congenital club-foot, juvenile growth facilitating ... 13 
Reduction of deformity by pressure and counter -pressure . . . 175,176 

Reduction of deformity of hip disease by Ridlon . 172 

Reduction of deformity of hip disease favored by growth . . . 159, 180 
Reduction of extreme deformity, traction and counter -traction in . . 175 
Reduction of rotating curvature by recumbency and suspension . 239-241 

Reduction of stature in Pott's disease . . . . 210 

Reflex contraction and confirmed by ankylosis, fixation initiated by . . 171 

Reflex muscular action described by Davis 172 

Reflex muscular action described by Verneuil 143 

Reflex muscular action in hip disease, discovery of 143, 144 

Reflex muscular action in hip disease, effect of . . 144, 149, 150, 171, 172 

Reflex muscular action in knee disease 81, 82 

Relapse to varus indicated by callus 15 

Relapsed, inveterate, and neglected club-foot . 16 

Relation of joint diseases to the centre of gravity of the body . . 100, 101 
Relaxation of straps of hip splint, causes of . . . . . . . . 118,119 

Release and fixation of jointed leg brace 37S9 

Release, bucket release and lever 38, 39 

Repair in hip disease, natural 87, 138 

Repair, rest and growth, Hilton on 1,4 

Repair, rest necessary to . 4 

Repair the repetition of growth 1 

Residuum of deformity and disability 62 

Resolution in lower extremities prevented by habitual traumatism . . 70 
Resolution induced by protection from traumatism .... 122, 123 
Resolution of joint inflammation in upper extremities ... 70, 88, 123 

Respiratory brace, French's 242 

Rest in lateral curvature, growth favoring effect of 243, 244 

Rest in treatment of inflammation 68, 69, 74 



INDEX. 269 

PAGE 

Rest in treatment of joint disease, definition of 68 

Rest necessary for flat-feet . 29 

Rest necessary to repair 4 

Rest, repair, and growth, Hilton on 1,4 

Resting by sitting on hip splint 113 

Results after third stage of hip disease, functional 158-160 

Results of hip disease, growth affecting 159 

Results of hip disease, mathematical appreciation of ... . 160-169 
Retention at a disadvantage from short leverage at hip .... 101,102 

Rhythm an early sign of hip disease, abnormal 142, 180 

Rhythm, diagrams of normal and abnormal 185, 186 

Rhythm easily modified during growth 180, 186, 187 

Rhythm in single congenital dislocation, normal 148 

Rhythm, lameness produced by abnormal and concealed by normal . 185 

Rhythm of human locomotion 118, 142, 148, 185-187 

Ribs, curvature of spine not reduced by pressure on 238 

Ribs, rotation aggravated by lateral pressure on 238 

Rickets, rounded back of 192 

Ridlon (Chicago), Dr. John 172 

Riser and tread of club-foot brace 10, 4S 

Rogers-Harrison (London, 181 1-90), Mr. Charles Henry 234 

Roller bandage replaced by laced legging 112, r 1 ; 

Romaine (New York), Dr. De Witt Clinton 82 

Ross (Altona, 1818-61), Gustav 103 

Ross (New York), Dr. William 149 

Rotating curvature illustrated in case of President Garfield 218,219 

Rotating curvature in leopards and other animals 225 

Rotating curvature, incidental and typical 234, 235 

Rotating curvature, unrecognized 225, 226 

Rotation adding graceful sinuosity to sigmoid curve 224 

Rotation adding serpentine element to lateral curvature . . . 217, 2 35 

Rotation affecting torso 225 

Rotation aggravated by lateral pressure on ribs 238 

Rotation and curvature inseparable 22^ 

Rotation, compensatory 223, 224, 234 

Rotation demonstrated by preparation of vertebral column, cause of 221-223 

Rotation described by Dods in 1824 217 

Rotation directly opposed by antero-posterior pressure .... 237, 238 

Rotation discovered by bimanual palpation of chest 227 

Rotation independent of flexion and extension of spine . . . 232, 233 
Rotation on central, peripheral, and remote axis 219-221 



270 INDEX. 

PAGE 

Rotation opposed by chest expansion 243 

Rotation recognized by Rogers-Harrison, cause of 234 

Rotation seen in gymnasium and in animals 225 

Rotation, theories of cause of 230-233 

Rotation, true theory of cause of 233 

Rotation, tumors caused by 225-227 

Rounded back of rickets and spastic contraction 192 

Rule for application of spinal brace 207 

Rule for management of hip splint at home 119,120 

Ruse to escape painful examination, boy's 151 

Rust, adhesive plaster applied to prevent 11, 36 

Sacroiliac disease, infrequency of 230 

Saddle-back of pseudo-hypertrophic muscular paralysis 194 

" Sailor gait " of congenital dislocation of hip 148 

Savarin (Paris, 1 755-1826), Jean Anthelme Brillat 27 

Sayre (New York, 1820-1900), Dr. Lewis Albert . . . . 90,91,98,229 

Scar without preceding sinus in hip disease 133 

Schapps (Pony, Montana), Dr. John Carpenter 59, 60, 86 

Sciatic scoliosis, Whitman on 229 

Sciatica marked by lateral curve of spine 228, 229 

Scoliosis, curved line of beauty in 235 

Scoliosis, kyphosis, and lordosis 193 

Scoliosis, sciatic 229 

Sculpture, effect of rotation on torso overlooked in 225 

Semi-tractable joint 173 

Sequence of causes of lateral curvature 244 

Serpentine effect of rotation in lateral curvature 217,235 

Shaffer (New York), Dr. Newton Melman 100,171 

Sherman (San Francisco), Dr. Harry Mitchell 66 

Shoe indicating relapse to varus 15 

Short hip splint 92 

Short leverage at hip-joint, disadvantage of 101,102,176 

Short limb, spinal curvature reduced by factitious lengthening of . . 181 

Short tendo Achillis, equine foot favored by 184 

Short tendo Achillis, locomotion not impaired by moderately . . . 21, 46 

Shortening, fracture of longer bone to neutralize 181 

Shortening neutralized by equine foot 154, 183-185 

Shortening produced by adduction, apparent . 161, 162, 165-167, 170, 171 

Shortening produced by disuse and overuse 181 

Shortening, real or structural and apparent .... 147, 170, 171, 180 



INDEX. 271 

PAGE 

Shoulder, Paget on quiet necrosis of 125 

Shoulder, vicarious mobility in ankylosis of 125 

Sigmoid curve of spine 224 

Significance of abscesses 139 

Signs and symptoms . . . . 142, 162, 228 

Silhouettes illustrating deformity of hip disease 165-167 

Sinuosity imparted to sigmoid curve by rotation 224 

Sinus in hip disease, scar without a 133 

Sinuses in exanthemata, deportment of 141 

Sinuses, effect of temporary closure of 141 

Sinuses in hip disease, location of 135,139,140,153 

Sitting and standing, composite sensation of 112,113 

"Sitting down," boy wearing hip splint thought he was 113 

Sitting position in Pott's disease, prosthetic apparatus for . . . 210,211 

Skeleton on outside, brace likened to 54, 207 

Smith (London), Mr. E. Noble 103, 234 

Smith (New York), Dr. Stephen 58 

Sole of shoe built up on outer border to oppose varus n 

Sole of shoe by steel in-sole, protection of 12 

Sole of shoe with an extension outward to oppose varus 11 

Spastic club-foot, growth affecting treatment of 16 

Spastic club-foot, weight of body in 16 

Spastic contraction, rounded back of . . 192 

Specialty, orthopaedic surgery as a 61 

Spinal brace, rule for management of 207 

Spinal landmarks, Whitman on 192 

Spondylitics, H. L. Taylor on rate of growth in 210 

Spontaneous dislocation, Hayward and March on 89 

Spontaneous opening of abscesses 131, 132, 214 

Spontaneous recovery from infantile paralysis ^^ 

Stability of knee promoted by hyperextension 35, 84 

Stamping club-foot straight 10, 13 

Standing and kneeling, composite sensation of 47 

Standing and sitting, composite sensation of 112, 113 

Stature in Pott's disease, reduction of 210 

Steel, apparatus improved by introduction of Bessemer 3 

Steel insole, protection of shoe by 12 

Steele (St. Louis), Dr. Aaron John 145 

Stephen Smith on importance of mechanical surgery 58 

Sternum, anterior deformity produced by caries of 215, 216 

Stevens (New York, 1 789-1 869), Dr. Alexander Hodgdon 90 



272 INDEX. 

PAGE 

Stomach pain in Pott's disease 142,191,192,197 

Straight, stamping club-foot . . . . 10, 13 

Strain on tendo Achillis, demonstration of 42-46 

Strain on tendo Achillis, Wirt on 46 

Stromeyer (Hanover, 1804-76), Dr. Louis 18 

Structural lengthening, Broca's case of 182 

Structural shortening, affections producing 147, 180, 181 

Structural shortening neutralized by equine foot .... 154, 183-185 
Subcutaneous surgery introduced by Stromeyer, Little, and Detmold 18-21 
Subcutaneous tenotomy postponed by fear of wounding tendons ... 3 

Subjective symptoms and objective signs 142,162,228 

Subluxation in knee disease 82, 85 

Surgery as a specialty, orthopaedic 61 

Surgery of the present day, conservative 67 

Surgery, recognition of mechanical 58 

Suspension, asthma relieved by 242 

Suspension by jury-mast in Pott's disease 203, 209 

Suspension, disappearance of lateral curvature during 241 

Suspension in lateral curvature, growth favoring effect of . . . 243, 244 

Suspiration by cadaver after suspension, audible 242 

Symmetrical locomotion fa cilitated by protection 177-179 

Symmetrical locomotion, deformity prevented by 177-179 

Symmetrical walking replacing lameness 185, 186 

Symmetry of deformed feet promoted by growth 5, 62 

Symptoms and signs 142, 162, 228 

Synovitis, chronic . 71 

Synovitis of hip-joint after typhoid fever 148 

Systematic drill in acquirement of correct rhythm 187, 188 

Tabetic talipes valgus 53 

Table of joint disease in upper and lower extremity 123 

Talipes of Friedreich's disease and locomotor ataxia 53 

Talipes varus and valgus, mechanics of production of 51 

Taylor (New York, 1827-99), Dr. Charles Fayette . . . . 3, 30, 70, 71, 

91,99, 112, 113, 127 

Taylor (New York), Dr. Henry Ling . 210 

Temporary closure of sinuses, effect of 141 

Tenacity of tuberculous possession 216 

Tendo Achillis, demonstration of strain on 42-46 

Tendo Achillis, equine foot favored by short 184 

Tendo Achillis, Hibbs on effect of dividing 46 



INDEX. 273 

PAGE 

Tendo Achillis in club-foot, division of 18 

Tendo Achillis inevitably elongated in paralysis 40 

Tendo Achillis, locomotion impaired by long . . 40, 46 

Tendo Achillis, locomotion not impaired by moderately short . . 21,46 

Tendons of leg, corner of ankle turned by 30 

Tendons of leg, flat-foot induced by constriction of 29, 30 

Tendons, tenotomy postponed by fear of wounding 3 

Theories of cause of rotation 230-233 

Theory of cause of rotation, true 233 

Therapeutic, prosthetic apparatus preventive and 60 

Third stage, details of application of hip splint in 115-117 

Third stage, functional results of hip disease in 158-160 

Third stage of hip disease, Hancock's description of patient in 114, 115 

Third stage of hip disease, intelligent expectation in 150 

Third stage of hip disease, weight and pulley in 117 

Thomas (Liverpool, 1833-90), Mr. Hugh Owen . . 88,99, 10;?, 172 

Toe in club-foot, inversion of 15 

Toe to upper part of leg, weight transferred from 12,47 

Toleration of mechanical treatment by children 55, 56, 63, 72 

Torso affected by rotation 225 

Townsend (New York), Dr. Wisncr Robinson 83 

Traction and counter-traction in reduction of extreme deformity . 17; 

Traction and fixation, correlation of 102, 104 

Traction and protection in hip disease, comparative importance of 122 

Traction by adhesive plaster an American invention 92 

Traction by adhesive plaster in hip disease, details of . 113,114 

Traction by weight and pulley or splint producing fixation . . 104,105 

Traction discontinued in favor of ischiatic support 120,121 

Traction formerly called extension 89 

Traction in hip disease, reasons for applying 98 

Traction with adhesive plaster in hip disease by Davis and Sayre ... 90 

Traction with adhesive plaster in fractures 89, 90 

Tragical illustration of rotating curvature 218, 219 

Trapezius muscle obscuring projection in cervical disease 195 

Trauma and tuberculous joint disease 65 

Traumatism and locomotion inseparable 126 

Traumatism, inflammation resolved by protection from . 70, 88, 122, 123 

Tread and riser of club-foot brace 10, 48 

Treatment of club-foot affected by weight of body . . . 7-9, 14-17, 22 

Treatment of hip disease, discontinuing 128, 129 

Treatment of joint disease and fracture, paradox in 106 

t8 



274 " INDEX. 

PAGE 

Treatment of knock-knee and bow-legs, growth affecting 79 

Treatment of lateral curvature determined by clinical observations . . 238 

Treatment of Pott's disease, nil desperandum in 201 

Treatment to be more urgent in periods of rapid growth ..... 2 

Tricycle riding and protection 126 

Trochanter to ilio-ischiatic line, relation of 169 

Tropical gums in manufacture of adhesive plaster 75 

True theory of cause of rotation 233 

Tuberculous action influenced by mechanical environment . . . 62, 123 
Tuberculous activity promoted by passive motion and brisement forctf 1 24 

Tuberculous deposits, operative removal of 66 

Tuberculous joint disease and innutrition 64, 65 

Tuberculous joint disease and trauma . .', 65 

Tuberculous joint disease depending on general reaction, recovery from . 72 
Tuberculous joint disease, intelligent expectation in treatment of . 4, 67, 68 
Tuberculous joint disease, mechanical or operative treatment of . 65-67 

Tuberculous joints certain to recover 67, 68, 72 

Tuberculous joints, duration of treatment of 71.72 

Tuberculous joints, natural repair and recovery of 67 

Tuberculous joints, upper extremity comparatively exempt from . 70, 123 

Tuberculous joints, weight of body to be removed from 68 

Tuberculous possession, tenacity of . . . • 216 

Tumor in Gideon MantelPs case, mistaken diagnosis of 226 

Tumors caused by rotation 225-227 

Twofold function of muscular system of joint 100 

Typhoid fever followed by synovitis of hip-joint 148 

Typical rotating or lateral curvature 235 



Ultimate deformity, juvenile growth in prevention of 72 

Uncertain origin, abscess of 214,215 

Unconscious correction of deformity of hip disease 178,179 

Uncorrected club-feet useful in locomotion 16 

Unexpected clinical features of Pott's disease 197 

Unmistakable signs of advanced hip disease 145, 146 

Unrecognized cases of lateral or rotating curvature 225,226 

Untwisting anterior part of foot by strip of adhesive plaster .... 12 

Ununited fracture, ischiatic crutch in treatment of 128 

Upper extremities, inflammation resolved in joints of . . . 70", 88, 123 
Upper extremities more exempt from effects of infantile paralysis . . ^t, 
Upper extremity comparatively exempt from tuberculous joints . . 70, 123 



INDEX. 275 

PAGE 

Value of protection and traction in hip disease, comparative . . . 122 

Varix producing hyperemia and lengthening, aneurysmal 182 

Varus and valgus divided by boundary plane 9 

Varus and valgus, mechanics of production of paralytic 51 

Varus, callus indicating relapse to 15 

Varus, Cook on treatment of talipes 11 

Varus opposed by elevating outer border of sole n 

Varying rates of growth, recognition of 2 

Verneuil (Paris, 1823-95), Aristide Auguste 91, 143 

Vertebra on central, peripheral, and remote axis, rotation of . . .219-221 

Vertebral column bisecting cavity of chest and abdomen 218 

Vertebral column demonstrating cause of rotation, preparation of 221-223 

Vertebral processes in Pott's disease, wiring 208 

Vicarious mobility in ankylosis of shoulder and of hip .... 125, 161 

Vicious circle in joint disease 93 

Vigilance muscidairc, Verneuil on 143 

Violence visiting joints of lower extremity in locomotion . . 123,124,126 

Visceral degeneration and abscesses 139 

Vision in horizontal plane preserved by extension of head . . . 194, 195 
Vital conduits converging at base of neck 212 

Wadding, cushions, and pads not necessary in apparatus .... 54 

Watson (New York, 1807-63), Dr. John 90, 103 

Weight and pulley applied by Brodie in hip disease 90, 99 

Weight and pulley demonstrated, production of fixation by . . 104, 105 

Weight and pulley in hip disease, Liston on 99 

Weight and pulley in third stage of hip disease 117 

Weight and pulley producing fixation in " Buck's extension" .... 105 
Weight and pulley reducing deformity of hip disease . . . . 117, 172 

Weight-bearing facilitated by hyperextension of knee 35» S4 

Weight of body affecting treatment of club-foot .... 7-9,14-17,22 

Weight of body as a factor of joint disease 123 

Weight of body to be removed from diseased knee and hip ... 74, 87 

Weight of body to be removed from tuberculous joints 68 

Weight of body to be removed in coxa vara 148 

Weight of body to be removed in knock-knee and bow-legs ... 79, 80 

Weight of body to be thrown on heel in flat-foot 30 

Weight thrown on ischium in artificial limb 126 

Weight transferred from toe to upper part of leg 12, 47, 49 

"Wheel, the human" 41 



276 INDEX. 

PAGE 

White swelling of knee by Romaine, early recognition of 82 

White swelling of knee, early diagnosis of 81,82 

White swelling of knee formerly requiring amputation .... 82, 83, 137 

White swelling of knee, home management of 85, 86 

White swelling of knee, hyperextension in 77, 83-85 

White swelling of knee, ischiatic crutch in treatment of ..... 81 
White swelling of knee, protection and fixation in treatment of . . 74, 85 

WTiitman (New York), Dr. Royal 192, 202, 209 

Willard (Philadelphia), Dr. De Forest 5 

Window in club-foot brace for exit of adhesive strip 13 

Wiring vertebral processes in Pott's disease 208 

Wirt (Cleveland), Dr. William Edgar . .' 46 

Wood (New York, 1817-82), Dr. James Rushmore 90 

Wooden high sole for well foot no 

Wounding tendons, tenotomy postponed by fear of 3 

Wrist disease, treatment of abscess of . . 124 

Wry -neck of cervical Pott's disease 194 

Wyeth (New York), Dr. John Allen 100 

Yale (New York), Dr. Leroy Milton 99 

Young (Philadelphia), Dr. James Kelly 196 

Zinc oxide replaced by India-rubber in adhesive plaster 75 



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